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September 4, 2013 Wednesday
Obamacare vs. Romneycare: The Labor Impact
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 748 words
HIGHLIGHT: Disruption to the labor market is likely to be far greater from the Affordable Care Act than what Massachusetts faced after it adopted its own health care law, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
From a tax perspective, the Affordable Care Act is in a different league than the Massachusetts health reform law passed in 2006.
The Affordable Care Act was intended to expand the fraction of the United States population covered by health insurance. The law includes taxes on employers and various implicit taxes on employees that go into effect over the next two years. Economic theory suggests that such taxes will contract the labor market in an amount commensurate with the amount of the new taxes.
The federal government and other advocates of Obamacare have dismissed concerns that the coming labor market contraction would be significant, or even noticeable, by pointing to Massachusetts's experience with its so-called Romneycare system, also designed to expand insurance coverage. Because the Massachusetts labor market did not noticeably contract relative to the rest of the nation after its system went into effect, an official of the federal Department of Health and Human Services told The Washington Examiner that the experience in Massachusetts suggested "that the health care law will improve the affordability and accessibility of health care without significantly affecting the labor market."
Prof. David Cutler of Harvard recently addressed, on this blog, concerns about possibly adverse tax effects, saying, "Additional data from Massachusetts, where a state law was the precursor to the Affordable Care Act, suggests that the fears are overblown" and "at this point the evidence overwhelmingly suggests no need for major worry."
This position assumes that the Massachusetts system increased marginal labor income tax rates in the state by roughly the same magnitude that the Affordable Care Act will increase them in the United States (by marginal labor income tax rate, I mean the extra taxes paid, and subsidies forgone, as the result of working, expressed as a ratio to the total compensation from working). This assumption is no longer necessary, because the methods I have used to measure marginal tax rates from the American Recovery and Reinvestment Act of 2009, unemployment insurance expansions and the Affordable Care Act can also be applied to the Massachusetts health reform law. The results are shown in the chart below.
The left bar shows that the Massachusetts law did, on average, increase marginal tax rates and thereby reduce the reward to working. But the impact was well under one percentage point, and for that reason it's probably not surprising that, relative to other states that were not experiencing health reform, the Massachusetts labor market did not change noticeably after the law went into effect.
The right bar shows the impact of the Affordable Care Act on nationwide marginal tax rates: it increases national rates about 12 times as much as the Massachusetts law increased rates. Earlier this year I explained why the Massachusetts law was so different from a tax perspective: among other things, its employer penalty is an order of magnitude less, the state's population is not the same as the national population, and Massachusetts had already been helping unemployed people with health insurance.
It follows that the effect of the Affordable Care Act on employment and work hours would be roughly 12 times as great as the effect of the Massachusetts law. That doesn't by itself tell us the exact impact of the national law because we don't have a precise estimate of the impact in Massachusetts, except that it was small. For example, if the Massachusetts law reduced employment by 0.1 percent, the Affordable Care Act's effect would be roughly 1.2 percent; not small. If the Massachusetts law's effect were 0.25 percent (still small), the Affordable Care Act's effect would be 3 percent: again, not small. The bottom line was that it was wrong to expect the two laws to have had the same effects.
Call me gloomy, but I'm one economist who thinks that adding, on average, five percentage points to marginal tax rates will noticeably depress the labor market, while adding a few tenths of a point in Massachusetts did not.
The Economics of the Affordable Care Act
Health Reform, the Reward to Work and Massachusetts
Affordable Care Act Could Be Good for Entrepreneurship
Massachusetts Employees Will Keep Their Health Plans
Health Coverage Worthy of a Senator
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October 14, 2013 Monday
The Hurdles to Success for the Affordable Care Act
BYLINE: PHILLIP SWAGEL
SECTION: BUSINESS; economy
LENGTH: 1756 words
HIGHLIGHT: The goals of the health-care law are laudable, but it is hobbled by unrealistic claims about its financing and heedlessness about its potential economic effects, an economist writes.
Phillip Swagel is a professor at the School of Public Policy at the University of Maryland and was assistant secretary for economic policy at the Treasury Department from 2006 to 2009.
The Affordable Care Act, or Obamacare, has had a difficult launching, but the more serious challenges for the law relate not to glitch-filled Web sites but rather to its possible long-term effects on the United States economy. The law is not likely to last if it imposes a severe drag on growth and job creation, or involves large costs obscured by the legislative gimmicks used to shape the scoring of the bill by the Congressional Budget Office. Indeed, Casey B. Mulligan has discussed the negative effects of the legislation on the American labor market in a series of posts on Economix, while the policy expert Charles Blahous explains in detail why the "fiscally reckless" legislation will aggravate the already difficult federal and state fiscal situations.
Along with philosophical reservations about expanding the role of the government in American society, these concerns about the negative economic and fiscal impact of the Affordable Care Act drive much of the opposition to it. Governors who declined to take up the expansion of Medicaid, for example, worried about the fiscal costs left to them even with the federal government picking up most of the tab.
At the same time, the goals of the legislation are laudable: to expand health insurance coverage, improve the quality of care and slow the growth of health costs. My view is that the presence of so many Americans without insurance or receiving inadequate health care is a moral affront to our affluent and generous nation. While at the Treasury Department, I worked on President George W. Bush's 2007 proposal to expand coverage through a change to the tax treatment of health insurance more progressive than the provision that ended up in the Affordable Care Act. And I was subsequently a co-author, with the tax expert Robert Carroll, of a market-based proposal that goes even further with tax code changes to both expand insurance coverage and improve incentives within the health care sector.
Still, the Affordable Care Act is the law of the land. Imagine then that the law worked - not just that the software glitches were resolved, but also that the legislation achieved its promise of expanding coverage while slowing cost growth and increasing the efficiency of the health care sector. This takes a huge amount of imagination, but under the best of circumstances here is how it might work.
As explained by the director of the Congressional Budget Office, Douglas Elmendorf, the Affordable Care Act improves insurance coverage by expanding Medicaid and by setting up exchanges on which people without access to affordable insurance can buy policies while receiving income-based subsidies to help cover the costs (and without having to worry about pre-existing conditions that might previously have made it difficult to afford insurance). A report by the White House Council of Economic Advisers says the expansion of coverage would increase societal well-being by an amount worth $100 billion per year, while the availability of policies through the exchanges would allow workers to switch jobs without losing coverage.
The White House report further notes that the exchanges would "'level the playing field' between large and small businesses" - insurance is often more expensive for smaller companies, which in turn are less likely to offer it to their workers, who then miss out on the favorable tax treatment for employer-provided coverage. The Affordable Care Act does not equalize the treatment of coverage between employers and individuals as in the approach proposed by Senator John McCain and favored by President Obama's economic advisers, but there is a rough trade-off in that employer-provided coverage retains the existing tax break while policies in the exchanges are subsidized for people with low incomes.
To prevent insurers that offer policies in the exchanges from having to cover only people with high health care costs, the Affordable Care Act includes a penalty for people who go without insurance. And to deter the unraveling of the current system of employer-provided coverage, businesses with 50 employees or more that do not offer health insurance will be required to pay a penalty (though this has been delayed a year, an inequity that administration officials find difficult to explain, including to the comedian Jon Stewart). It remains to be seen whether these penalties are large enough to motivate young, healthy people to take up insurance, while companies might see paying the penalty as less costly than offering coverage.
For workers with low wages, the subsidies in the exchanges are generally more valuable than the tax deduction for employer-provided coverage, so they might actually come out ahead from the abandonment of President Obama's promise that they could keep their existing coverage and see their usual doctors (the balance ultimately depends on how workers' wages change when employers shunt them over to the exchanges).
Providing insurance to millions more people will increase the use of health care services. This is a policy objective of the Affordable Care Act, but it means more spending, so the law includes measures meant to slow the growth of health costs. Some Medicare providers will be paid for the treatment of an illness as a whole (an "episode of care") rather than for individual procedures, a change meant to give providers incentives to avoid unnecessary treatments. A tax will be imposed on very costly health insurance plans to give an incentive to avoid policies with generous coverage, and payments reduced to certain Medicare plans and to providers such as hospitals. An Independent Payment Advisory Board is to propose changes to Medicare to improve quality and reduce cost growth, with the recommendations to take effect unless Congress votes otherwise, rather than the current system in which a commission makes recommendations that can be ignored.
Health care cost growth has slowed in recent years, though as The Times reported in February, it is not yet clear "what is driving the lower spending trajectory." Still, proponents of the Affordable Care Act hope that its cost-reducing provisions will be more effective than expected by the Congressional Budget Office, and thus the fiscal outcome will be to save money rather than the roughly budget-neutral score estimated by the budget office if the provisions of the law are put in place.
Sticking to the law as enacted will be challenging, since government actuaries have stated that some of the payment cuts in the law are so severe as to jeopardize access to care by Medicare recipients. Similarly, the Affordable Care Act increased payments for treating Medicaid recipients, but only for 2013 and 2014; allowing these to go back down could make it difficult for those in the newly enlarged Medicaid program to find a doctor willing to treat them. If the higher payments are meant to be extended, however, then this means that the full costs of the Affordable Care Act are not accounted for in the law. It is noteworthy that reductions in Medicare overpayments were a putative funding source for the legislation, but underpayments such as those for doctors were not addressed. In other words, the cost of the law is again understated.
The Affordable Care Act imposes a variety of new taxes to cover part of the cost of providing coverage to millions of additional people, including taxes on high-cost health insurance plans, medical devices, tanning salons, and capital gains and dividends. This last provision is a penalty on people who save and invest; the administration uses the Orwellian phrase that it is a contribution. And these taxes are already under siege: it is possible that the medical device tax will be reversed as part of the current fiscal negotiations, while unions are pushing to modify the tax on high-cost health plans even before it takes effect.
Some of the financing behind the Affordable Care Act already disappeared when the administration acknowledged that it was not possible to develop a financially viable long-term insurance plan. Finally, the administration has repeatedly boasted that the law extends the life of the Medicare trust fund, even though the Medicare payment reductions that supposedly accomplish this cannot be spent both to finance the Affordable Care Act and to shore up Medicare. This implies that part of the financing behind the Affordable Care Act has in effect already been devoted to something else. If costs are higher than expected and some of the tax revenues do not materialize, the law as a whole could well turn into a largely unfunded new entitlement. So much for the new era of fiscal responsibility promised by Mr. Obama.
With the main provisions of the Affordable Care Act kicking in only in 2014 and the health insurance and health care industries adjusting to it for some time, it will take years for a proper evaluation of the law's overall impact on the economy. The question is whether the objective of helping many people to obtain insurance coverage can be accomplished at a cost that is acceptable to society, both in terms of the cost to taxpayers who ultimately will pay and the possible effects of slower economic growth from those taxes and other distortions introduced in the law.
Just as opponents of the law are apt to overstate its negative impacts with claims of "death panels," so too are proponents overly optimistic in underplaying its fiscal and economic consequences. The administration's misleading response to the scope of problems with the exchange Web sites is especially worrisome. The goals of the Affordable Care Act are laudable. But achieving them will require an honest assessment of both successes and problems, and a willingness to make adjustments going forward. This sort of critical introspection is not exactly a defining feature of the president or his administration. Millions of Americans could be helped by the Affordable Care Act once its start-up problems are resolved. Not much further down the road, however, President Obama's signature accomplishment could turn into yet another fiscal mess left to his successor.
Dealing With Drafting Errors in the Health Care Law
When the Treasury Runs Out of Cash
The Path to Complexity on the Health Care Act
A Health Care Fight That Punishes Federal Workers
Medicare's Lessons for the Affordable Care Act
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August 7, 2013 Wednesday
The Economics of the Affordable Care Act
BYLINE: DAVID M. CUTLER
SECTION: BUSINESS; economy
LENGTH: 1524 words
HIGHLIGHT: Casey Mulligan’s negativity about the Affordable Care Act fails to acknowledge how it is likely to reduce health care expenditures, an economist writes.
David Cutler is Otto Eckstein Professor of Applied Economics at Harvard University. He served as senior health care adviser to the Obama presidential campaign in 2008.
Will the Affordable Care Act help or hurt the economy? At a time when economic growth remains mild and the employment outlook is mixed, answering this question is of fundamental importance.
The negative case is easy to understand. The law has a number of provisions that may inhibit employment and growth, including an employer mandate to pay for health insurance coverage (now delayed), increases in the Medicare contribution rate for high-income workers and taxes on medical device companies, health insurance companies and tanning salons. Many economists worry about the economic impact of these provisions (though fewer about the tax on tanning salons).
Casey Mulligan has just presented the gloomy situation on this blog, and he did so well. Professor Mulligan is a serious and concerned analyst; his views are not the rant of those who see death panels lurking around every corner. Indeed, many issues that Professor Mulligan highlights are topics that have drawn public concern; for example, Darden Restaurants (owner of Red Lobster and other chains) drew immense attention - much of it negative - when it announced that it would increase use of part-time labor to avoid the payment requirements for full-time workers under the Affordable Care Act.
Interestingly, the most widely expected adverse effects of the Affordable Care Act have yet to materialize, despite the fact that it has been in place for nearly three years. As a recent chart released by the President's Council of Economic Advisers shows, hours of work are up in the restaurant industry since March 2010. The same is true in the vast bulk of retail businesses where the option to move workers from full to part time is a real one. It may be that companies are waiting until the employer mandate kicks in - or it could be that the fears of significant adverse effects were overblown.
Additional data from Massachusetts, where a state law was the precursor to the Affordable Care Act, suggests that it is the fears that are overblown. Two studies, one by Jonathan Kolstad and Amanda Kowalski and a second by Lisa Dubay, Sharon Long and Emily Lawton, found very little adverse effect from the employer and individual mandates on employment; workers valued the insurance greatly, so the mandate was actually a benefit for them.
It is possible that the differences between the Massachusetts and federal laws will lead to a different result for the Affordable Care Act, but at this point the evidence overwhelmingly suggests no need for major worry.
The Benefits of Cost Reduction
In looking at the totality of the Affordable Care Act, what is most noticeable for the economy is the good news that it promises for American workers and businesses. The most important component of the act is what it will do to the costs of medical care. For the last 25 years (see Table 5, Page 24, of from the National Federation of Independent Business), small businesses have ranked the cost of health insurance as the most critical problem they face. It is no wonder why: rising health insurance costs are associated with increases in total compensation, reduced competitiveness vis-à-vis other companies and increased human-resource problems.
The link between health costs and employment is increasingly clear. A study by Neeraj Sood, Arkadipta Ghosh and José Escarce shows that industries that provided health care to more of their workers in 1986 had significantly lower employment growth between 1987 and 2005. No similar relationship was observed in Canada, where businesses do not pay for health insurance, confirming the role of health care in the relationship. Another study from Katherine Baicker and Amitabh Chandra looks at area-level cost increases in the United States and reaches a similar conclusion.
A fundamental question about the Affordable Care Act is thus what it will do to employer spending on health insurance. The act has a number of provisions designed to reduce spending growth. These include the "Cadillac tax" on expensive health insurance plans and a transition of medical care payments away from fee-for-service payment into value-based payments. Economists are virtually united in asserting that a combination of these demand and supply-side levers are the way to get a handle on a wasteful system.
Already, these payment transitions seem to be having an effect. Health care cost increases are at the lowest level in the last half-century, and employer premium growth has slowed markedly. My own work with Nikhil Sahni shows that the Affordable Care Act is one factor in this slowdown.
In the testimony that Professor Mulligan mentioned and the analytic work behind it (done jointly with Professor Sood), I estimated that slowing cost growth along the lines made possible by the Affordable Care Act would lead to 250,000 to 400,000 jobs gained annually over the next decade. The effects would increase over time.
In the public sector, the impact of a cost slowdown is more difficult to assess. The federal government typically responds to increased Medicare and Medicaid costs by borrowing more. Lower national savings means less investment in plant, equipment and other productive activities. Using standard economic models, the President's Council of Economic Advisers estimated that slowing medical care cost increases by 1.5 percentage points annually (and effectively borrowing less) would lead to gains in the gross domestic product of 2 percent by 2020 and 8 percent by 2030.
Down the road, higher costs mean either higher taxes or reduced services. Neither the sequester nor the Medicare tax increase in the Affordable Care Act would have been necessary if Washington had dealt with health spending some time back. Similarly, state and local governments have cut education spending, laid off teachers and hired fewer police and fire fighters in response to higher benefit costs. A slowdown in cost growth could bring some of these jobs back.
Professor Mulligan discounts the possibility of implicit tax cuts in the future and does not consider the benefits of any additional spending that may result from lower public-sector health costs; implicitly, his analysis assumes that government spending is all wasteful. I disagree. Making room for productive investment in our economy is one of the major potential benefits of the Affordable Care Act.
Impact on the Work Force
At the work force level, the Affordable Care Act reduces or eliminates many distortions, even as it creates some others. The economist Brigitte Madrian showed nearly two decades ago that many workers were "locked" into their jobs because they had health insurance on a current job and might not be able to maintain that coverage if they switched jobs. Universal insurance coverage would free workers to move to their most productive job or to start a business. Other studies have shown that greater access to health insurance encourages people on disability insurance to work more, reducing the cost for that program.
Then there are the costs of workers missing work (absenteeism) or being less productive at work because they are ill. Common conditions like mental illness, back pain and persistent headaches lead to each of these. Each is treatable but all are undertreated, in part because people are uninsured or underinsured. A recent study pegged the costs of absenteeism and productivity losses on the job at more than $200 billion annually, or about 1.5 percent of G.D.P.
The Affordable Care Act will not eliminate these costs - people will still get sick, after all - but it is likely to reduce them. The recent Oregon Health Study, for example, found that people who gain insurance are much less likely to suffer from depression than their less fortunate peers who remain uninsured.
Are the benefits from reduced job lock, greater work among disability insurance recipients, and less absenteeism and workers ill on the job greater than the potential distortions from shifts into part-time work and increases in marginal tax rates? I do not know; no one has added up the various costs and benefits. For that reason, I did not highlight the work force implications of the Affordable Care Act when I testified before Congress. Instead, I focused on the cost savings implications of the act, which are immense and likely to be more important. I am glad that this forum allows Professor Mulligan and me a chance to discuss these other effects.
What is most clear is that the current health care system is failing families, businesses and governments. The Affordable Care Act is the most serious effort ever made to address the myriad flaws in health care today. If it works as intended, the health of our economy - as well as our people - will be much improved.
Affordable Care Act Could Be Good for Entrepreneurship
Massachusetts Employees Will Keep Their Health Plans
Health Coverage Worthy of a Senator
Health Reform, the Reward to Work and Massachusetts
Health Care Inflation and the Arithmetic of Labor Taxes
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August 7, 2013 Wednesday
Health Care Inflation and the Arithmetic of Labor Taxes
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 1421 words
HIGHLIGHT: Data and arithmetic make clear that the Affordable Care Act could have negative effects on employment, despite the optimism of the law’s supporters, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
A modest reduction in health care inflation by itself might increase employment or number of hours worked, but the effect will be overwhelmed by new taxes coming into effect in the next two years.
Health care and the labor market are connected because so much of the non-elderly population obtains health insurance through an employer or the employer of a family member. As the decades have gone by, Americans have been spending more and more on health care, largely through their health insurance premiums, to the point that many families cannot afford the kinds of health insurance plans in which middle- and upper-income families take part.
So it's reasonable to wonder whether the health expenditure trends affect the amount of employment in the economy, and thereby whether policy reforms that reduce the rate of health expenditure growth might reverse some of those employment effects.
The direction of the employment effects of health care inflation is unclear, because it depends on the reasons for rising health care costs. To the degree that rising costs derive from new, valuable (but expensive) pharmaceuticals and medical procedures, rising costs may make people more attached to jobs with health benefits in order to have better access to medical innovations and to pay for them with pretax dollars.
But health economists have also pointed to less benign sources of health care inflation, including excessive malpractice penalties and a number of other health industry inefficiencies that raise employer health insurance costs without creating commensurate value for employees.
The economists Katherine Baicker and Amitabh Chandra looked at evidence suggesting that malpracticelike sources of health care inflation are economically equivalent to an implicit tax on employers (see Page 612 of their paper). Economists call it an "implicit tax" because it has many economic characteristics of a tax, even though it is not legally a tax; it reduces employee cash wages by the amount of the implicit tax, and incentive-sensitive employees respond by working less.
As the House of Representatives began to consider whether to repeal the Affordable Care Act, David Cutler of Harvard testified about the Baicker-Chandra results and asserted that the Affordable Care Act would reduce average health care costs by about 5 percent by 2015, reduce the health care cost implicit tax on employers and thereby increase nationwide employment more than it would have grown had the Affordable Care Act not been enacted.
He also organized and signed an economists' letter to Congress asserting that "repealing the Affordable Care Act would produce job reductions of 250,000 to 400,000 annually." The Affordable Care Act was cutting employer costs and Congress needn't worry that it would contract the labor market, they wrote.
Neither Professor Cutler's testimony nor the economists' letter mentioned that the Affordable Care Act also creates explicit taxes on employers, subsidies for layoffs and various implicit taxeson employees with many of the same economic characteristics as taxes on employers.
Other advocates of the Affordable Care Act dismiss the act's work disincentives as negligible, because incentives supposedly have little effect on employment and hours worked. At first glance, it might seem that we have a case of dueling experts, and that we'll never know which effect dominates. But that first impression would be incorrect, because each effect cited above - like the employer mandate or the health care cost reduction - is a tax effect, and simple arithmetic is all that is needed to determine the direction of the combined effect of all of the tax-like provisions.
After I sent Professor Cutler a draft of this post, he responded: "When I was giving my testimony, I was excluding the vast bulk of policies that will affect part-time work, job choice, etc., because I wanted to focus on the overall cost issue. I don't think you can do this right unless you include all the effects."
He agreed with me that readers of his testimony and letter might get the wrong impression that "repealing the Affordable Care Act would produce job reductions" refers to the act as a whole, when it fact it refers to the cost-reduction provisions by themselves. (He also said that neither his testimony nor my calculations quantify the effect of the health care law on job mobility and on the health of the work force, and that he believes these two employment effects to be large. I will return to those issues in a later post.)
Furthermore, Professor Cutler told me he left out explicit and implicit tax effects because he believed (and still believes) them to be less than the cost-reduction effects, and because he "didn't have a way to add them all up," referring to the various effects. Since Professor Cutler's testimony, I have shown how most of the effects can be added together because cost reduction is a tax effect comparable to the tax effect of the employer mandate, the tax effect of the subsidy for layoffs and so on (see also the methodology in Chapter 3 of my book "The Redistribution Recession").
Begin with Professor Cutler's (probably optimistic) estimate that the act will reduce employer health costs by 5 percent as of 2015. Because of the special payroll and income tax treatment of employer health insurance, 1.5 of those five percentage points of savings will accrue to government treasuries, leaving 3.5 percentage points of health care savings for employers and employees. Americans spend about 18 percent of their gross income on health care and 82 percent on other things: saving 3.5 percent on health care is like saving 0.6 percent on their total budget.
(In principle, the government treasuries could use their savings to cut marginal tax rates or increase them less than they would have. But they could also use the savings to pay for additional assistance programs that erode work incentives, so I take the middle ground and assume that the government savings by itself has no effect on marginal tax rates.)
Some cost-reducing provisions in the Affordable Care Act, such as the tax on "Cadillac" health plans or the Independent Payment Advisory Board, may reduce value received by employees at the same time that they reduce employer costs, and therefore affect employment less than cutting implicit employer taxes does. The implicit tax cut effect associated with the act's cost reductions (as estimated by Professor Cutler) is therefore somewhere in the range of 0.3 to 0.6 percentage points, with the 0.6 percentage point case representing the extreme where none of the cost-saving measures reduces employee value.
The Affordable Care Act's explicit taxes on employers, subsidies for layoffs and implicit taxes on employees, together amount to a five or six percentage point addition to the average marginal tax rate on labor income (this includes the fact that many people will not take part in programs for which they are eligible, the tendency of the act to move people off means-tested uncompensated care and the fact that the act implicitly taxes unemployment benefits, as I noted in testimony before the Human Resources Subcommittee of the House Ways and Means Committee). By these calculations, the tax effects that Professor Cutler left out are about 10 times greater than, and in the opposite direction of, those he conveyed to Congress.
Professor Cutler projected that the Affordable Care Act's cost reductions by themselves will increase employment in 2015 by about 400,000, or about 0.3 percent of total employment (see Figure 2 in his testimony). If his estimate of the cost-savings channel is accurate, and I am right that the overall labor market effect of the act is about 10 times larger (in the other direction) than the cost-savings channel, we might then expect the act to contract the 2015 labor market by about 3 percent rather than expand it.
As time goes by and additional research results become available, it increasingly appears that even the experts failed to fully appreciate the labor-market-depressing effects of the Affordable Care Act at the time it was passed.
Who Abandoned the Health Insurance Credit
What Makes U.S. Health Insurance Exchanges So Complicated
The Path to Complexity on the Health Care Act
The New Economics of Part-Time Employment
Putting Off the Employer Mandate
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March 19, 2014 Wednesday
'Romneycare' and the 29ers
SECTION: BUSINESS; economy
LENGTH: 534 words
HIGHLIGHT: The Affordable Care Act is far more likely to cause disruptions in the labor market than the Massachusetts health reform of 2006, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Health reform in Massachusetts in 2006 did not cause many workers to have their work hours cut, but that is no comfort for those workers nationwide who will begin to experience this side effect of the federal Affordable Care Act.
Business executives have been saying that they have, or will be, cutting workers' hours to avoid penalties levied by the Affordable Care Act. Because the penalties are applied only to full-time workers (defined by the law as working 30 hours a week or more), redefining a worker as a part-time - a "29er," as they are sometimes called - might save the employer money and enhance profits.
But a skeptical listener might not interpret the executives' statements literally. In any economy, there are businesses that struggle, and maybe it's too easy to blame the unpopular new law for deeper business difficulties.
Massachusetts also had a health reform law - sometimes called "Romneycare" after Gov. Mitt Romney, who signed it - with some of the same elements as the Affordable Care Act, including penalties on employers that did not offer health coverage to their employees. Yet Massachusetts did not seem to experience a crisis of 29ers when Romneycare was implemented.
The Washington Examiner quoted an unidentified Department of Health and Human Services official as saying that the experience in Massachusetts suggests that "the health care law will improve the affordability and accessibility of health care without significantly affecting the labor market." But a closer look shows that the Massachusetts experience tells us little about the number of 29ers that will be created by the Affordable Care Act.
For one, the Romneycare employer mandate was not based on the number of full-time employees. It was based on the number of full-time-equivalent employees, which means that workers are counted according to the number of hours they work, not their full-time status.
For example, cutting all workers' hours to 39 from 40 would have the same penalty consequence under Romneycare as would cutting 1/11th of workers' hours to 29 from 40. In Massachusetts employers could choose how to cut employee hours (if at all) on the basis of business and personal considerations; the federal law would only give relief to the 29er approach.
Second, the Romneycare penalty was deductible from an employer's business taxes; the Affordable Care Act's penalties will not be deductible. A Massachusetts employer avoiding the health reform's penalty would find that his avoidance increased his business tax liability a bit.
Finally, the Romneycare penalty was only about $300 per full-time equivalent employee, whereas the Affordable Care Act's penalty is $2,000 and set to grow with the rate of health care inflation.
For now, it may be worth listening to what the business executives are saying.
The Employer Mandate: Dukakis All Over Again
The Economics of Being Kinder and Gentler in Health Care
The Slow Death of the Employer Mandate
Obamacare vs. Romneycare: The Labor Impact
The Economics of the Affordable Care Act
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(You're the Boss)
October 1, 2013 Tuesday
What Does the Affordable Care Act Mean for Your Business?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 397 words
HIGHLIGHT: If you are a small-business owner with employees, please take a few minutes to fill out the survey.
It's been three and a half years since the Affordable Care Act became the law of the land, and the enormous changes it will bring to the American health insurance market are upon us. As of Tuesday - glitches and delays aside - small-business owners and individuals are able to begin shopping for health insurance policies on online exchanges, and in many cases receive tax credits to offset the cost.
There are preliminary indications that the health care law may already be having positive impacts on both individual premiums and underlying medical costs. But setbacks have bedeviled the law, especially the parts specifically aimed at small companies. The tax credits to help small businesses defray the cost of covering employees have been judged too parsimonious by some to induce many businesses to obtain new coverage. The Internal Revenue Service has been slow to write rules governing the law's so-called employer mandate. The Small Business Health Options exchanges, as they are known, have had several problems - including the White House's recent acknowledgement that small businesses will not be able to enroll online through the exchanges until November. (They should be able to enroll by phone or fax this month.)
As the Affordable Care Act has lurched toward implementation, the voices of small businesses have been somewhat missing from the discussion of what happens next - at least, that is, the unmediated voices of small businesses. Advocates on both sides of the issue are always happy to find a small-business owner with a pre-existing point of view when a reporter calls.
With the law upon us, The Times would like to hear directly from small-business owners. We've put together an online questionnaire to ask how you have prepared for the Affordable Care Act's arrival and the concrete ways that you think it may affect your business. If you are a small-business owner with employees, please take a few minutes to fill out the survey. We'll use the results to inform our reporting in the hope that it will help all of us understand what the changes mean and what is likely to come next.
A Health Insurance Offer for the Busy Start-Up
Business Owners Say They Have Yet to Figure Out Health Care
Employer Mandate, Delayed by Paperwork (and Efforts to Reduce It)
It's the Affordable Care Act. But What Is Affordable?
In the Affordable Care Act, Some Children Left Behind
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The New York Times
January 23, 2017 Monday 00:00 EST
Senators Propose Giving States Option to Keep Affordable Care Act
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 981 words
HIGHLIGHT: Bill Cassidy of Louisiana and Susan Collins of Maine, both Republicans, say states could also choose to receive federal money for their own plans.
WASHINGTON - Several Republican senators on Monday proposed a partial replacement for the Affordable Care Act that would allow states to continue operating under the law if they choose, a proposal meant to appeal to critics and supporters of former President Barack Obama's signature health law.
But the plan was attacked by Democrats as a step back from the Affordable Care Act's protections, and it was unlikely to win acceptance from conservative Republicans who want to get rid of the law and its tax increases as soon as possible. If anything, the proposal - by Senators Bill Cassidy of Louisiana, a medical doctor, and Susan Collins of Maine, a moderate Republican - may show how difficult it will be for Republicans to enact a replacement for the Affordable Care Act.
Legislation that can pass muster in the more conservative House may not win enough support in the Senate. A bill with broad appeal in the Senate may fail in the House.
Under the proposal, states could stay with the Affordable Care Act, or they could receive a similar amount of federal money, which consumers could use to pay for medical care and health insurance. "We are moving the locus of repeal to state government," Mr. Cassidy said. "States should have the right to choose."
The proposal shares some features with House Republican proposals: It would encourage greater use of health savings accounts and eliminate the requirement for most Americans to have insurance or pay a tax penalty. But the option for states to keep the Affordable Care Act alive will rankle the most conservative Republicans who have been trying for nearly seven years to blow it up.
"Obamacare is flawed, failing and not fixable, and it needs to be fully repealed," said Representative Mark Meadows of North Carolina, the chairman of the House Freedom Caucus.
A stalemate between the House and Senate would leave in place Mr. Obama's health law, but efforts by President Trump and Congress to undermine it could send health insurance markets into a tailspin. On Friday, as one of his first official acts as president, Mr. Trump signed an executive order that could allow officials to ease up on enforcement of the mandate requiring most Americans to have insurance.
Supporters of the Affordable Care Act panned the Cassidy-Collins proposal. "Millions of Americans would be kicked off their plans, out-of-pocket costs and deductibles for consumers would skyrocket, and protections for people with pre-existing conditions, such as cancer, would be gutted," said the Senate Democratic leader, Chuck Schumer of New York.
Ronald F. Pollack, the executive director of Families USA, a liberal-leaning consumer group, said the bill "falls way short of providing the protections and coverage people have under the Affordable Care Act."
Ms. Collins said the bill would allow states to "keep the Affordable Care Act if it is working for their residents." But she predicted that most states would choose something different.
Under the Cassidy-Collins bill, states could enroll people who would otherwise be uninsured in health plans providing basic coverage. These high-deductible health plans are intended to protect consumers against catastrophic medical expenses. They would cover generic versions of prescription drugs, and they would also have to cover recommended childhood immunizations without co-payments. States would contract with one or more insurers to offer this coverage.
Consumers could buy "more robust coverage" if they want, Mr. Cassidy said, but they could be automatically enrolled, by default, in the high-deductible health plans providing basic coverage. "A state could say, 'All those eligible are enrolled unless they choose not to be,'" he explained.
This "passive enrollment" would provide insurers with a large pool of customers, including many healthy people, without the coercion of an "individual mandate," Mr. Cassidy said.
"We think that we could cover more people than Obamacare," Mr. Cassidy said, although he acknowledged that the effects of his bill had not been analyzed by the Congressional Budget Office, which serves as Capitol Hill's official scorekeeper.
If a state opts out of the Affordable Care Act, many of the federal insurance standards established under the law would no longer apply. The bill would repeal federal benefit mandates that "often force Americans to pay for coverage they don't need and can't afford," Mr. Cassidy said.
But some protections would remain in place. Parents would still be allowed to keep children on their insurance until the age of 26, and insurers could not impose annual or lifetime limits on benefits.
The Cassidy-Collins bill, called the Patient Freedom Act, would eliminate not only the unpopular individual mandate, but also the federal requirement for larger employers to offer coverage to full-time employees.
Mr. Cassidy said that Senators Shelley Moore Capito of West Virginia and Johnny Isakson of Georgia, both Republicans, were also sponsors of the bill.
The Senate majority leader, Mitch McConnell, Republican of Kentucky, and the No. 2 Senate Republican, John Cornyn of Texas, were sponsors of a similar bill that Mr. Cassidy introduced in 2015. But the legislative landscape is different now. Republicans in Congress can repeal the Affordable Care Act, with support from Mr. Trump. In the Senate, they will need help from Democrats to adopt a replacement because Republicans are eight votes shy of the 60 needed to stop a filibuster.
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PHOTO: Senators Susan Collins and Bill Cassidy introduced legislation on Monday in Washington to replace the Affordable Care Act.(PHOTOGRAPH BY J. SCOTT APPLEWHITE/ASSOCIATED PRESS)
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February 26, 2014 Wednesday
The Affordable Care Act's Multiple Taxes
SECTION: BUSINESS; economy
LENGTH: 886 words
HIGHLIGHT: A new tax created by the Affordable Care Act and little noticed to date is likely to have significant impact on the labor market, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The Affordable Care Act contains at least two economically distinct taxes on labor market activity. Even the experts on the law have failed to recognize all of them.
The Affordable Care Act tries to make health insurance affordable by offering means-tested subsidies and tax credits to households so they can make their payments for monthly health insurance premiums and out-of-pocket health expenses like deductibles and copayments for medical services.
This assistance is means-tested because higher-income households get less assistance than lower-income households. As a household's income rises, it has to pay more for the same coverage. As a matter of economics, it wouldn't have been much different if the law had given assistance to all households and then paid for it with a new income tax that was capped once household income hits 400 percent of the federal poverty line.
Naturally, income taxes discourage people from doing the things that create income. This is not to say that everyone responds to every tax, just that the average result of an additional income tax is less income.
Economists have long understood and publicized the implicit income taxes that come with attempts to make health care affordable. As my fellow Economix blogger Uwe Reinhardt put it 20 years ago (in an article with Alan B. Krueger) about one specific subsidy plan, health insurance premium assistance "would present millions of low-income American families with total marginal tax rates in excess of 75 percent." Professor Reinhardt also noted recently that the marginal tax rate implicit in any particular health insurance proposal depends very much on the features of that plan.
The Congressional Budget Office also highlighted this issue as the Affordable Care Act was going through Congress. Daniel P. Kessler, a Stanford professor, also discussed it in a commentary in 2011.
Under the Affordable Care Act, only a small minority of workers is expected to get subsidized coverage. So economists concluded that aggregate labor market effects of the new law would be minimal.
I would agree if the implicit income tax were the only new tax on labor market activity in the new law. But there's more: The Affordable Care Act also contains a new implicit tax on employment that affects far more people than its implicit income tax does.
Income taxes and employment taxes are not the same, because the income tax is based on income and the employment tax is based on employment. Two households with the same family structure (in number and age of family members) and annual income who live in the same county will not necessarily get the same assistance from the Affordable Care Act. The household that is employed more months of the year is likely to get less assistance (and maybe no assistance) from the new law, because the law requires that, during the months that they are employed, full-time workers get health coverage from their employer before they turn to the new health insurance marketplaces for federal government subsidies.
To put it another way, even if the health insurance subsidies in the Affordable Care Act had been a specific dollar amount that was not phased out with household income, the law would still act as a tax on employment because most workers could not get the assistance during the months they were at work.
This new implicit employment tax will apply to tens of millions of workers who are offered health insurance on their job and to millions of non-employed persons who are considering a position that offers coverage.
(The new employment tax also changes the types of jobs that are created and accepted by workers, but this effect does not prevent the law from reducing employment, as Trevor Gallen and I explain).
As far as I know, before this month the only place that one could read about the Affordable Care Act's new employment tax was in by David Gamage, in posts I have written for this blog, in my 2012 book or in a 2013 paper. Even though the consequences of the law have been debated at least as far back as 2009, the law's advocates have yet to acknowledge the new implicit employment tax, let alone estimate the number of people who will face it.
But in a recent paper, the Congressional Budget Office has joined me in explaining that it's not just the implicit income tax that will contract the labor market. As the paper puts it, "The loss of subsidies upon returning to a job with health insurance is an implicit tax on working," adding that the effect of the new tax is "similar to the effect of unemployment benefits" (see Page 120).
Once we consider that the new law has an employer penalty, too, the labor market will be receiving three blows from the new law: the implicit employment tax, the employer penalty and the implicit income tax. Regardless of how few economists acknowledge the new employment tax, it should be no surprise when the labor market cannot grow under such conditions.
A Report's Real Message: It Wasn't About Health Care
Policies That Discourage Full-Time Work
The Power of the Individual Mandate
Medicaid and the Incentive to Work
The Hurdles to Success for the Affordable Care Act
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January 24, 2017 Tuesday
Late Edition - Final
A G.O.P. Health Care Bill Would Let States Opt In
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 936 words
WASHINGTON -- Several Republican senators on Monday proposed a partial replacement for the Affordable Care Act that would allow states to continue operating under the law if they choose, a proposal meant to appeal to critics and supporters of former President Barack Obama's signature health law.
But the plan was attacked by Democrats as a step back from the Affordable Care Act's protections, and it was unlikely to win acceptance from conservative Republicans who want to get rid of the law and its tax increases as soon as possible. If anything, the proposal -- by Senators Bill Cassidy of Louisiana, a medical doctor, and Susan Collins of Maine, a moderate Republican -- may show how difficult it will be for Republicans to enact a replacement for the Affordable Care Act.
Legislation that can pass muster in the more conservative House may not win enough support in the Senate. A bill with broad appeal in the Senate may fail in the House.
Under the proposal, states could stay with the Affordable Care Act, or they could receive a similar amount of federal money, which consumers could use to pay for medical care and health insurance. ''We are moving the locus of repeal to state government,'' Mr. Cassidy said. ''States should have the right to choose.''
The proposal shares some features with House Republican proposals: It would encourage greater use of health savings accounts and eliminate the requirement for most Americans to have insurance or pay a tax penalty. But the option for states to keep the Affordable Care Act alive will rankle the most conservative Republicans who have been trying for nearly seven years to blow it up.
''Obamacare is flawed, failing and not fixable, and it needs to be fully repealed,'' said Representative Mark Meadows of North Carolina, the chairman of the House Freedom Caucus.
A stalemate between the House and Senate would leave in place Mr. Obama's health law, but efforts by President Trump and Congress to undermine it could send health insurance markets into a tailspin. On Friday, as one of his first official acts as president, Mr. Trump signed an executive order that could allow officials to ease up on enforcement of the mandate requiring most Americans to have insurance.
Supporters of the Affordable Care Act panned the Cassidy-Collins proposal. ''Millions of Americans would be kicked off their plans, out-of-pocket costs and deductibles for consumers would skyrocket, and protections for people with pre-existing conditions, such as cancer, would be gutted,'' said the Senate Democratic leader, Chuck Schumer of New York.
Ronald F. Pollack, the executive director of Families USA, a liberal-leaning consumer group, said the bill ''falls way short of providing the protections and coverage people have under the Affordable Care Act.''
Ms. Collins said the bill would allow states to ''keep the Affordable Care Act if it is working for their residents.'' But she predicted that most states would choose something different.
Under the Cassidy-Collins bill, states could enroll people who would otherwise be uninsured in health plans providing basic coverage. These high-deductible health plans are intended to protect consumers against catastrophic medical expenses. They would cover generic versions of prescription drugs, and they would also have to cover recommended childhood immunizations without co-payments. States would contract with one or more insurers to offer this coverage.
Consumers could buy ''more robust coverage'' if they want, Mr. Cassidy said, but they could be automatically enrolled, by default, in the high-deductible health plans providing basic coverage. ''A state could say, 'All those eligible are enrolled unless they choose not to be,''' he explained.
This ''passive enrollment'' would provide insurers with a large pool of customers, including many healthy people, without the coercion of an ''individual mandate,'' Mr. Cassidy said.
''We think that we could cover more people than Obamacare,'' Mr. Cassidy said, although he acknowledged that the effects of his bill had not been analyzed by the Congressional Budget Office, which serves as Capitol Hill's official scorekeeper.
If a state opts out of the Affordable Care Act, many of the federal insurance standards established under the law would no longer apply. The bill would repeal federal benefit mandates that ''often force Americans to pay for coverage they don't need and can't afford,'' Mr. Cassidy said.
But some protections would remain in place. Parents would still be allowed to keep children on their insurance until the age of 26, and insurers could not impose annual or lifetime limits on benefits.
The Cassidy-Collins bill, called the Patient Freedom Act, would eliminate not only the unpopular individual mandate, but also the federal requirement for larger employers to offer coverage to full-time employees.
Mr. Cassidy said that Senators Shelley Moore Capito of West Virginia and Johnny Isakson of Georgia, both Republicans, were also sponsors of the bill.
The Senate majority leader, Mitch McConnell, Republican of Kentucky, and the No. 2 Senate Republican, John Cornyn of Texas, were sponsors of a similar bill that Mr. Cassidy introduced in 2015. But the legislative landscape is different now. Republicans in Congress can repeal the Affordable Care Act, with support from Mr. Trump. In the Senate, they will need help from Democrats to adopt a replacement because Republicans are eight votes shy of the 60 needed to stop a filibuster.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/01/23/us/politics/senate-affordable-care-act-bill-cassidy-susan-collins-trump.html
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GRAPHIC: PHOTO: Senators Susan Collins and Bill Cassidy introduced legislation on Monday in Washington to replace the Affordable Care Act.(PHOTOGRAPH BY J. SCOTT APPLEWHITE/ASSOCIATED PRESS)
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July 2, 2013 Tuesday
Confusing the Public on the Affordable Care Act
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1286 words
HIGHLIGHT: Many opponents of the Affordable Care Act have used cautionary warnings of its impact, and some of them are jam-packed with misleading information, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
In my previous post I explained that general statements on the probable impact of the Affordable Care Act on the pocketbooks of Americans often do not make sense and can be quite misleading.
My point can be illustrated with a recent news release from the Ohio Department of Insurance, "Health Insurance Costs to Increase Significantly Under Affordable Care Act." The department states that it "released the information today to help health insurance consumers continue to prepare for the expected price increases." It offers a one-sided perspective.
In its announcement, the department reports:
The department's preliminary analysis of the proposed plans for the individual market reveal that insurers expect the cost to cover health care expenses for consumers will significantly increase. Based on a report released by the Society of Actuaries earlier this year, the department estimates this increase is an average of 88 percent. ... A total of 14 companies filed proposed rates for 214 different plans to the department. Projected costs from the companies for providing coverage for the required essential health benefits ranged from $282.51 to $577.40 for individual health insurance plans.
Presumably these numbers refer to claims cost and not premiums.
The release is silent on whether the reported average of $420 of this wide range of claims costs are those for a given benefit package or an average over quite different benefit packages. If the former, how could the range of cost claims be so wide? If the latter, the reported average of these numbers would be meaningless. After all, how informative would it be to say that the average cost for a group of cars is $110,422, when that includes Chevrolets, Jeeps, BMWs and Ferraris?
If properly informing consumers had been truly the department's intention, it should have added at least two additional pieces of information.
First, the news release should have reminded readers explicitly that income-related federal subsidies toward health insurance premiums will be available for individuals with household incomes up to 400 percent of the federal poverty level, along with "cost-sharing subsidies" toward out-of-pocket costs for families with incomes between 100 and 250 percent of the federal poverty level. For lower-income people, these subsidies will significantly offset premiums driven up by the reported 88 percent increase in costs.
Second, the news release might have included some explanation of why the "cost to cover health care expenses for consumers" in Ohio is expected to rise as a result of the Affordable Care Act.
A clue to the answer can be gained from the study by the Society of Actuaries cited by the department.
That study reports average claims costs per member per month for what it calls the "pre-A.C.A." and the "post-A.C.A." state of affairs. The pre-A.C.A. figure represents estimated claims cost per insured person per month in 2014 if the Affordable Care Act did not exist. The post-A.C.A. estimate reflects the counterfactual assumption that the entire act has been fully carried out in 2014, something that actually will occur only by the latter half of the decade.
Using a highly complex simulation model, the actuaries estimate that if the Affordable Care Act were fully carried out by 2014, the average claims cost per member per month in Ohio's nongroup risk pools would rise from an estimated pre-A.C.A. level of $223 (Figure S-2, Page 8) to the post-A.C.A. level of $406, an 82 percent increase, assuming no expansion of Medicaid in Ohio. The increase in systemwide total health spending in Ohio brought on by the Affordable Care Act, however, is estimated to be only 3.2 percent.
Aside from the fact that the minimally accepted package of essential benefits under the Affordable Care Act will be more generous and costly than many of the much leaner policies traditionally sold in the nongroup market, that can leave people exposed to high financial risk, a major driver of the projected cost increase - one explicitly flagged by the actuaries - is a projected change in the risk profile of the insured in Ohio's nongroup market.
The Society of Actuaries projects that the number of individuals insured in that market will increase from the pre-A.C.A. level of 415,000 to the post-A.C.A. level of one million. Many of these newly insured are projected to be relatively sicker individuals who had been excluded from Ohio's nongroup market, either because they could not afford the high premiums they were quoted, based as these were on the individual's health status; or because insurers had refused them coverage outright; or because they were in the state's high-risk pool.
Just last week Julie Appleby of the Kaiser News Network reported on the tribulations that individuals had routinely experienced in the current, pre-A.C.A. nongroup market.
The proponents of the Affordable Care Act should not deny that with this simulated change in the risk profile of Ohio's nongroup insurance market - which may or may not come about - a switch from medically underwritten premiums to community-rated premiums, coupled with a richer benefit package, could significantly raise premiums for healthy individuals with higher incomes who are not entitled to substantial federal subsidies or any at all. The Ohio Insurance Department's news release certainly drives home that point.
On the other hand, for projected new entrants into Ohio's nongroup market who are relatively less healthy, the community-rated premiums even before federal subsidies are most likely to be significantly lower than their medically underwritten pre-A.C.A. premiums - if they had been offered coverage at all. A forthright news release would have mentioned that positive outcome as well.
From the "fact sheet" that the Department of Insurance appended to its news release, one gathers that Ohio's lieutenant governor, Mary Taylor, who also acts as director of the Department of Insurance, opposes the Affordable Care Act and supports its repeal. In the fact sheet, her department notes:
Health insurance today is priced based on individual characteristics. Those with healthier lifestyles are rewarded with more affordable options. Under the A.C.A., all Ohioans will be lumped together for the purposes of pricing thereby eliminating the benefits of healthier choices. This method of rating is commonly known as "community rating. ... Because Ohio is being forced into this type of pricing, health insurance costs are increasing in 2014.
I can understand how community rating violates the theory of justice espoused by libertarians. In fact, I have proposed a way to accommodate their preferred social ethic. The department's rationale for opposing what it calls "one-size-fits-all pricing," however, astonishes me.
One can agree that an individual's choice of an unhealthy lifestyle can reduce her or his health status and increase that person's use of health care. Community rating gives such people a financial break we would rather not give them.
But many serious and often devastating illnesses afflicting individuals are a result of accidents, or genetic or environmental factors that have little to do with lifestyle choices. The many victims of such illnesses, in Ohio as elsewhere, might interpret the Ohio Insurance Department's rather crudely put theory of the causation of illness as an insult added to injury.
The New Economics of Part-Time Employment
Putting Off the Employer Mandate
'Premium Shock' and 'Premium Joy' Under the Affordable Care Act
The New Subsidy for Layoffs
Affordable Care Act Could Be Good for Entrepreneurship
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November 25, 2013 Monday
The Single-Payer Alternative
BYLINE: NANCY FOLBRE
SECTION: BUSINESS; economy
LENGTH: 900 words
HIGHLIGHT: A single-payer system of health insurance would be more consumer-friendly, as well as more cost-effective than the Affordable Care Act, an economist writes.
Nancy Folbre is professor emerita of economics at the University of Massachusetts, Amherst.
Rush Limbaugh's take on the disastrous rollout of the Affordable Care Act could, ironically, warm the hearts of those at the other end of the political spectrum. He contends that President Obama knew all along that the Affordable Care Act would crash and burn, but pushed it through so that the conflagration would clear the way for single-payer health insurance.
The conspiracy charge sounds deranged, but problems with the new health insurance system may indeed revitalize demands for more substantive reforms, which many policy makers and voters set aside in the putative interests of political pragmatism. Whatever the advantages of a single-payer system such as that currently administered by Medicare, one view held, American voters were unlikely to get behind it.
Yet one of the greatest advantages of a single-payer system - its relatively low administrative costs - have been thrown into sharp relief by problems registering with the new health exchanges. And while Republicans despise the Affordable Care Act despite its conformity with many of their earlier proposals, their proposed changes (other than simple rollback) look complicated, kludgy and costly to administer.
The malfunctioning website has magnified problems inherent in coordinating enrollment across many different companies in many different exchanges in cooperation with many different government agencies. The harmonization challenges are orders of magnitude greater than those faced by a single company or a single state, making streamlining difficult. Improved software can do only so much.
In theory, competition and choice should increase efficiency. In practice, health insurance companies are able to take advantage of the complexity and uncertainty surrounding health care choices to make comparison shopping very difficult.
Lack of clear information about the prices of medical procedures, combined with a proliferation of insurance options whose potential benefits will be strongly affected by unpredictable events (such as being involved in an automobile accident or developing cancer), put consumers in a weak position.
The process of negotiating relationships with new health care providers because old ones are "out of network" is physically and emotionally exhausting. Insurance companies benefit from promoting policies that are difficult to understand and make consumers fearful of any change in their coverage. That fear and aversion has spilled over into the transactions required for many people to benefit from the Affordable Care Act.
David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, regularly assert that elimination of the huge paperwork and overhead imposed by private insurance companies could save enough to cover the estimated 31 million of Americans who will remain uninsured under the Affordable Care Act.
My fellow Economix blogger Uwe E. Reinhardt, expanding on this theme, notes that the Institute of Medicine of the National Academy of Sciences recently estimated excess administrative costs of $191 billion, again more than enough to attain truly universal health care coverage.
Most such estimates are limited to the monetary costs incurred by insurers, doctors and hospitals and don't include the value of the time that health care consumers must devote to managing a torrent of inscrutable paperwork that can become truly frightening for the critically ill.
Even if its rollout becomes more expeditious, the Affordable Care Act does little to reduce the incentives that companies have to barricade themselves behind high information and transaction costs. In the financial sector, I previously noted, this perverse incentive is described as "strategic price complexity."
A complicated new program applied to a complicated old industry makes it hard for everyone to figure out exactly what they will be getting relative to what they are paying. As a result, many ordinary people and small businesses fall prey to redistributional paranoia.
Accusations of ripoffs proliferate, along with assertions that the Affordable Care Act is unfair to young people or that it simply represents transfers from the affluent to the poor, or from whites to people of color.
The program clearly has redistributive impact, but much of it will be muted over the life cycle. People who pay more for their insurance will get more benefits in return. The biggest transfers will go from the healthy to the sick (who are sometimes poor precisely because they are sick) and from one part of the health care system (emergency room care) to another (insurance-covered routine care).
But the structure of the program seems unintentionally designed to intensify distributional conflict. Its highly means-tested subsidies create strong political resentments and contribute to very high implicit marginal tax rates on lower-income families.
A single-payer insurance system, whether based on an extension of Medicare or on the Canadian model, promises many profoundly important benefits. Right off the mark, it promises simplicity.
No wonder conservative pundits are afraid of it.
The Midterm Grade for HealthCare.gov
The Hurdles to Success for the Affordable Care Act
Dealing With Drafting Errors in the Health Care Law
The Path to Complexity on the Health Care Act
Putting Off the Employer Mandate
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March 28, 2012 Wednesday
Further Reading on Mr. Mandate
BYLINE: CATHERINE RAMPELL
SECTION: BUSINESS; economy
LENGTH: 231 words
HIGHLIGHT: A bibliography on Jonathan Gruber, the health economist who helped design the Affordable Care Act and the Massachusetts health plan enacted under Gov. Mitt Romney.
I have a profile now online about Jonathan Gruber, an economics professor at M.I.T. He helped design both the universal health care overhaul in Massachusetts and the Affordable Care Act, and is probably the economist most closely associated with the idea of an individual insurance mandate.
Here's a short bibliography on Mr. Gruber, for those interested in reading more about the professor and his work.
His M.I.T. home page.
Links to his op-ed articles and to his academic journal articles.
A comic book he wrote about the Affordable Care Act.
A Q.&A. last year with Slate.
An MSNBC interview with Mr. Gruber about the anniversary of RomneyCare, and Mr. Gruber's thoughts about Mitt Romney's condemnation of the Affordable Care Act.
A New Yorker article last year by Ryan Lizza, describing the genesis of RomneyCare and Mr. Gruber's role in forming the legislation.
His most recent study on what happens if the mandate is struck down, and policy alternatives that have been proposed.
Some (extremely) technical documentation on his health care micro-simulation models.
A PowerPoint presentation he did as part of his consulting for Wisconsin's health department, published by The Daily Caller.
Is U.S. Health Spending Finally Under Control?
The Wyden-Ryan Plan: Deja Vu All Over Again
Social Insurance and Individual Freedom
Vermont's Move Toward Single-Payer Health Insurance
Health Reform Comic Book
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April 3, 2014 Thursday
6 Q's About the News | Obama Claims Victory in Push for Insurance
SECTION: EDUCATION
LENGTH: 217 words
HIGHLIGHT: How many Americans have signed up for private health insurance plans under the Affordable Care Act?
In "Obama Claims Victory in Push for Insurance," Michael D. Shear and Robert Pear write about a milestone for the Affordable Care Act. Use the video above as well as the article to answer these questions:
HOW many Americans have signed up for private health insurance plans under the Affordable Care Act?
WHAT happened last October when HealthCare.gov first opened that made it a "bureaucratic and technical nightmare"?
WHAT did President Obama mean by saying, "Armageddon has not arrived"?
WHAT questions that will help determine the law's success are still to be answered?
WHY do many Republicans want to repeal the Affordable Care Act?
WHEN is the next open enrollment season?
WHOM, if anyone, do you know who has signed up for health insurance under the Affordable Care Act?
For Higher-Order Thinking
The article describes this milestone as "more significant politically than for what it says about the law's potential impact on the American health system." WHY?
WHY is it important to the success of the law that as many young, healthy people as possible sign up
Beyond the Rhetoric: Researching and Writing About the Health Care Law
6 Q's About the News | Possible U.S. Government Shutdown Looms
6 Q's About the News | Senate Votes to Move Forward on Budget Debate
Supreme Court Rules on Health Care
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The New York Times
October 27, 2014 Monday
The New York Times on the Web
Trajectory of Costs Levels Off, but There Are Many Reasons
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section ; Column 0; National Desk; SPENDING; Pg.
LENGTH: 820 words
Health care spending had begun slowing even before the Affordable Care Act was signed into law.
The reasons included recession, higher-deductible policies that discourage people from seeking health care services, and a decline in the development of new, costly prescription drugs.
But reductions in wasteful or unneeded care may also be factors in the slowdown, and experts say the Affordable Care Act may help reinforce those changes.
In the short term, the law could actually drive up health care spending by bringing more insured people into the system.
For decades, health care costs have been rising much faster than the rest of the American economy, outrunning inflation and wages and driving a growing imbalance in the federal budget. With the Affordable Care Act, President Obama promised to slow it all down. The law, he said often, would ''bend the cost curve,'' flattening health spending's precipitous rise and making health care more affordable for the country.
The last few years have seen a significant slowdown in the growth of health spending. Across nearly every measure -- medical price growth, employer insurance premiums, per capita Medicare spending -- the amounts the country spends on health care have increased by much smaller margins than the nation is used to.
But it is hard to make a case that the Affordable Care Act deserves substantial credit for the recent trend -- though it may be helping to nudge it along. The spending slowdown began before the law was even written. The major provisions of the law intended to slow down spending growth have mostly come in the form of small-scale experiments, and studies of those programs have shown mixed results.
The law's signature Medicare initiative, the Accountable Care Organization, has yet to demonstrate the savings its authors promised; recent results from the Department of Health and Human Services show that only a fraction of participating systems have succeeded in saving money.
Meanwhile, the growth in health spending has been slowing down around the world, suggesting that the cause may not be something special happening in this country.
Health economists have been alternately celebrating the slowdown and puzzling over it. A series of studies have tried to examine what factors have caused it, with an eye to determining whether the trend is here to stay. The typical answer includes the recession (individuals and hospitals, facing financial stresses, reduced their health care spending); the rise of high-deductible health insurance plans; the loss of patent protection for many blockbuster drugs, leading to the use of more low-cost generics; and changes in the way medical care is being delivered.
Those changes in health care delivery are the most likely among all the factors to be related to health policy. The authors of the Affordable Care Act believed that the key to wringing dollars out of the health care system was reducing unnecessary and wasteful care that cost money without helping patients. If the health care system is starting to do that, and new policy helps reward the welcome change, then there is a chance that the trend could hold.
Optimists about the Affordable Care Act tend to point to hospital readmissions -- when a patient leaves the hospital only to bounce back within a month -- as an example of how policy is helping medical care become cheaper and better. Historically, hospitals had little financial incentive to prevent readmissions since they got paid for both visits. The Affordable Care Act began imposing penalties on hospitals with a lot of readmissions, and in just a few years the number declined. But readmissions represented only a tiny fraction of medical spending, so they cannot explain too much of the overall slowdown.
For that reason, Peter R. Orszag, the former Obama administration budget director and now a vice chairman at Citigroup, thinks that the Affordable Care Act should get only partial credit for the slowdown. ''I view it as kind of an accelerant and reinforcement,'' he said of the law.
In the short term, the health law could actually increase health care spending. Recent measures of the gross domestic product already show an uptick in the use of health care services this year, the expected effect of expanding health insurance coverage to millions of Americans who did not have it before. Even if the price of services is not going up and medical practice is less wasteful, more people seeing doctors and filling prescriptions is going to cost more money.
But the real long-term test of the health law will be whether, once those new people are absorbed into the system, the current downward trend in spending growth can be sustained.
''The experiment is on, and everyone knows they're a lab rat,'' said Douglas J. Holtz-Eakin, the president of the right-leaning American Action Forum and a former director of the Congressional Budget Office. ''Now we'll see if it sticks.''
URL: http://www.nytimes.com/2014/10/27/us/has-the-law-contributed-to-a-slowdown-in-health-care-spending.html
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The New York Times
January 13, 2017 Friday 00:00 EST
The Republicans vs. Obamacare;
Letters
SECTION: OPINION
LENGTH: 590 words
HIGHLIGHT: Readers fault the Republicans for a rash act.
To the Editor:
Re "The Fight for Health Care Has Begun" (column, Jan. 10): David Leonhardt is correct about the Republicans' wish to crush the Affordable Care Act. But their likely strategy is one of neglect. They will shout "repeal, repeal" and cause such confusion that some insurance companies will drop out, premiums will rise and patients will be so uncertain about their options that they will not sign up.
The G.O.P. will then say "see, it's a failure" and offer unworkable travesties like high-risk pools. The Republicans can then move on with their real agenda to privatize Medicare and provide starvation block grants to unravel Medicaid.
JAMES WEBSTER
Santa Fe, N.M.
The writer is professor emeritus of medicine at the Feinberg School of Medicine, Northwestern University.
To the Editor:
Re "Trump Orders Swift Remake of Health Act" (front page, Jan. 11):
Poor Donald! He apparently believed the Republican rhetoric that Obamacare failed. In publicly exhorting his party's congressional majority to repeal the Affordable Care Act and come up with a replacement at or near the same time, he doesn't realize that his party doesn't have and never did have a replacement, despite years of its repeated votes to repeal the law.
And the only effective replacement that won't explode the deficit would either be essentially the same as the Affordable Care Act or a single-payer insurance system. Sad!
SHARON MORRISON
Whitefish, Mont.
To the Editor:
The reason Republicans can't come up with a replacement for the Affordable Care Act is that it was their plan in the first place. It was devised at the conservative Heritage Foundation, enacted in Massachusetts by Gov. Mitt Romney, a Republican, and is essentially a market-based system to require people to buy private health insurance.
Privatization is the Republicans' solution to every problem (see also: education, infrastructure), and now that President Obama has tried it, they have nowhere else to turn. It is hard to understand how this simple truth has escaped attention in the public discourse.
ROBERT NEUGEBOREN
Cambridge, Mass.
To the Editor:
Re "Health Lobby Quiet as Law Faces Repeal" (front page, Jan. 10):
Why are the health care lobbyists and executives "stunned" at the speed with which the Republicans are trying to repeal the Affordable Care Act in Congress? Election Day should have been their wake-up call to expect and prepare for yet another bill to repeal Obamacare.
You report that the president of the Greater New York Hospital Association said health care executives "don't want to get on the wrong side of the new administration or the Republican majority in Congress." These health care executives seem to cower rather than stand up for the millions who could lose health care coverage and watch as the health system is dismantled.
At this pivotal time, we need those in power to stand up for what is right and honorable especially for those in need.
JACQUELINE JONES
Portland, Ore.
To the Editor:
I doubt that companies "were afraid to speak out" merely because "they feared that Mr. Trump would attack them on Twitter." Unlike Donald Trump, companies don't have fragile egos that can be damaged by a tweet. They might lose some customers, but probably not a decisive number.
More likely, the companies are afraid that Mr. Trump will mark them for revenge, and use presidential powers to exact it. They may also fear that business partners will shun a company at odds with Mr. Trump.
Such thinking is common in dictatorships. Is that where we're headed?
ILYA SHLYAKHTER
Cambridge, Mass.
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April 23, 2017 Sunday
Late Edition - Final
Obama's Health Law: A Tale of 2 Red States
BYLINE: By ABBY GOODNOUGH and REED ABELSON; Abby Goodnough reported from Bartlesville, and Reed Abelson from New York.
SECTION: Section BU; Column 0; Money and Business/Financial Desk; Pg. 1
LENGTH: 1629 words
BARTLESVILLE, Okla. -- When President Trump describes the Affordable Care Act as ''imploding,'' Lori Roll, an insurance agent here, does not consider it hyperbole.
Only one health insurer in Oklahoma is left selling coverage through the federal marketplace, and the hospital in this city of 36,000 is not in the network. Premiums are among the highest in the country, and while most marketplace customers qualify for the Affordable Care Act's income-based subsidies that lower the cost, many of Ms. Roll's middle-class clients do not.
''A lot of them are friends,'' she said, ''and I'm having to tell them: 'My God, your premium just doubled. I'm so sorry.'''
In neighboring New Mexico, also under Republican leadership, the Affordable Care Act marketplace is in far better shape. Marketplace customers can still choose among four insurers, and the state has one of the lowest average premium costs.
Nearly four years after they opened, the Affordable Care Act's insurance marketplaces, also known as exchanges, are not uniformly failing, as Mr. Trump claims. Instead, they have risen or fallen in no small part because of political and policy decisions by each state. New Mexico embraced the law, and its marketplace has been healthy, while Oklahoma resisted at every step, and its marketplace is foundering.
But now both states are worried that political maneuvering at the federal level may deeply destabilize the marketplaces. In an effort to get Democrats to negotiate, Mr. Trump has threatened to stop paying more than $7 billion in subsidies to insurers that don't charge deductibles and co-payments to millions of poor people. Uncertainty about the subsidies, which are a critical financial underpinning of the law, may drive more insurers out of the market -- leaving Oklahoma with no health plans in the marketplace -- and raise premiums significantly higher for those that stay.
Politics at both the state and federal levels have been critical to shaping the success and failure of the Affordable Care Act. Oklahoma and New Mexico offer a case study of how that has played out.
New Mexico expanded Medicaid as soon as the law allowed, oversees its marketplace and conducts vigorous outreach to draw in potential customers, moves that have most likely helped attract healthier customers.
Oklahoma has raged against the law since its passage, challenging its subsidies in a lawsuit and refusing to expand Medicaid or set up its own state-run insurance exchange. Instead, the federal government runs the state's marketplace through HealthCare.gov, an option taken by more than two dozen mostly Republican states.
''I was never for Obamacare from the beginning,'' John D. Doak, the Oklahoma insurance commissioner, said in an interview at his office, where a red trucker hat that says ''Make Health Insurance Great Again'' sits on his desk.
The uninsured populations in both New Mexico and Oklahoma have fallen since the law took effect. But New Mexico's progress has been stronger, even though it started with a higher rate of uninsured.
Oklahoma's uninsured rate was the third highest in the country in 2015, the most recent year available: 13.9 percent, according to the Census Bureau, compared with 17.7 percent in 2013, just before the Affordable Care Act's coverage provisions took effect. New Mexico's uninsured rate fell to 10.9 percent in 2015 from 18.6 percent in 2013.
Here in Bartlesville, an oil town that has felt the economic impact of the drop in oil prices, the anger that Ms. Roll and many of her clients feel is directed more at the health law -- and its champion, former President Barack Obama -- than at the state's unyielding resistance to it.
''You don't get on the Titanic when you know it's going to sink,'' said David Moore, 51, who owns a fishing tackle business.
Mr. Moore, a self-described ''libertarian guy'' who voted for Mr. Trump, avoided a doubling of his premiums this year by switching to a small group health plan with his wife, an audiologist, and one of her employees. But Mr. Moore, who earns too much to qualify for premium subsidies under the Affordable Care Act, still had his monthly premiums increase sharply for his plan covering his family of four, to $1,100 from $700, with a $12,000 deductible.
''My biggest problem with this is our government picking winners and losers,'' Mr. Moore said, referring to the fact that lower-income people get large subsidies under the law and higher-income people do not. ''I'm a loser. And it should not be this way.''
Cameron Jarrett, 31, is equally disappointed with his insurance options, even though his employer gives him money toward his premium and he gets a subsidy, too. He pays the rest: $303 a month for a Blue Cross plan that covers his family of three, with a $12,000 deductible.
Still, Mr. Jarrett, another Trump voter who wants the Affordable Care Act repealed, does not entirely blame the law.
''States like Oklahoma that sit on their hands and do nothing -- that's not helping,'' he said. ''If we're going to do this, let's give it every opportunity to work, even if it's not a policy I agree with over all.''
Mr. Trump and Republicans in Congress have repeatedly pointed to markets like Oklahoma's, with just a single insurer, as a sign that the Affordable Care Act exchanges are deeply troubled. But Oklahoma's individual market has never been very competitive. In New Mexico, several local insurers have long competed on the individual market, but Blue Cross has been the dominant player in Oklahoma for years, and is now the only insurer offering plans on the exchange. Even when other insurers offered plans through the Affordable Care Act marketplace during its first few years, Blue Cross scooped up by far the most customers.
In addition to big decisions, like whether to expand Medicaid, some seemingly minor ones may have influenced the marketplaces' health. Oklahoma has continued to allow about 45,000 people to keep old policies that do not meet Affordable Care Act standards. People with this type of ''transitional'' policy tend to be healthy, and may have helped the risk pool if they had been required to buy insurance through the exchange. Oklahoma is also one of three states that do not review insurers' proposed rates from year to year, ceding the job to the federal government instead.
In New Mexico, on the other hand, insurance regulators did not allow people to keep their old plans and required any insurer that sold plans through the Affordable Care Act marketplace to offer them in every county. John G. Franchini, the state's superintendent of insurance, has also negotiated rates with insurers, even denying a 52 percent increase requested by Blue Cross and Blue Shield of New Mexico for 2016.
Now, seven years after Mr. Obama signed the Affordable Care Act into law, Oklahoma is changing its stance and seeking a more active role. The state is preparing to ask the federal government's permission to change how the law works here through waivers allowed under the law. One of its proposals is to help very poor people afford private plans by giving them subsidies.
The state may also ask for permission to ''re-evaluate'' and perhaps reduce the package of essential benefits that the Affordable Care Act requires every insurance plan to have. And it wants plans under the law to be sold not through the federal marketplace, but through a program called Insure Oklahoma, which has provided subsidized coverage to a subset of low-income residents here since before the health law took effect.
The changes, which the state hopes would make insurance more affordable and provide more choices, would have to be approved by the Trump administration and in some cases by the Legislature. Most would not go into effect until 2019 at the earliest.
Meanwhile, Oklahoma, which has faced a series of budget crises because of the oil industry downturn, does not have the money to help pay insurers' costs next year, as Alaska and Minnesota are doing. So Oklahoma is looking to the Trump administration and Congress to help stabilize its marketplace in time for next year and persuade Blue Cross to stay.
Mr. Doak raised alarms last month when he wrote in a letter to Gov. Mary Fallin, a fellow Republican critic of the health law, that Blue Cross was ''making preparations to withdraw'' from the marketplace. Blue Cross, which is operated as a nonprofit insurance company, said it had not made a final decision about next year.
''We certainly want to continue to offer products in 2018,'' said Kurt Kossen, an executive at Health Care Service Corporation, Blue Cross's parent company.
Mr. Doak said that without any stabilization funds or other federal efforts to stabilize the individual insurance market, another round of steep premium increases was inevitable here.
But Blue Cross plans have been doing better in the marketplaces, and Health Care Service Corporation, which offers plans in Oklahoma, New Mexico and three other states, is losing less money. It aggressively raised prices last year, with a 75 percent average rate increase in Oklahoma.
A major factor in the insurers' losses was the decision by Congress not to fully fund a program aimed at protecting insurers during the early years of the Affordable Care Act, when the companies did not know what to charge. Mike Rhoads, the deputy insurance commissioner, said Blue Cross ''started too low,'' with some of the lowest prices in the country in 2014.
Regulators in both states say that now, the fate of the marketplaces depends very much on the actions of Congress and the Trump administration.
''We're just a little boat in this ocean,'' said Mr. Franchini, the New Mexico superintendent. ''If there's a tidal wave from Washington, it could scuttle us.''
URL: https://www.nytimes.com/2017/04/21/health/how-gop-in-2-states-coaxed-the-health-law-to-success-or-crisis.html
LOAD-DATE: April 23, 2017
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: David Moore of Bartlesville, Okla., who owns a fishing tackle business, is among many Oklahomans with strong reservations about the Affordable Care Act. ''You don't get on the Titanic when you know it's going to sink,'' he said of the health law. (BU1)
Top, Cameron Jarrett with his son, Henry, in Bartlesville, Okla. Of the Affordable Care Act he said, ''If we're going to do this, let's give it every opportunity to work.'' Above, John D. Doak, Oklahoma's insurance commissioner, said that without federal help, premium increases were inevitable. Below, Lori Roll, an insurance agent in Bartlesville, said she has had to tell clients: ''My God, your premium just doubled. I'm so sorry.'' (PHOTOGRAPHS BY SHANE BROWN FOR THE NEW YORK TIMES) (BU4)
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October 20, 2014 Monday
Ohio Governor Backpedals on Repeal of Health Law
BYLINE: TRIP GABRIEL
SECTION: US; politics
LENGTH: 344 words
HIGHLIGHT: Gov. John Kasich of Ohio said his comments about a Republican-led Congress being unlikely to repeal the Affordable Care Act were taken out of context.
Wait, that's not what I really meant.
Gov. John Kasich of Ohio said his comments about a Republican-led Congress being unlikely to repeal the Affordable Care Act - which commentators on the right and left pounced upon Monday - were taken out of context.
Mr. Kasich, a Republican mentioned as a 2016 presidential hopeful, in an interview distanced himself from the notion that he had accepted the health care law as a fait accompli. The idea is anathema to almost all Republican officials, and especially the party's base.
In an Associated Press article about nine Republican governors who have expanded Medicaid, Mr. Kasich, referring to repealing the Affordable Care Act, was quoted as saying "that's not gonna happen."
He insisted that his comment referred only to a repeal of the Medicaid expansion option, not the entire act. (Late Monday evening, The A.P. updated its report to include the governor's clarification.)
"I've always thought if we got a majority we would repeal Obamacare,'' he said. "My only point was they'd probably make an accommodation for Medicaid expansion.''
The governor was trying to control the damaging perception, not to say fatal for a would-be Republican presidential candidate, that he supports the Affordable Care Act.
Mr. Kasich pushed Medicaid expansion through Ohio's Republican-led Legislature over the opposition of Tea Party lawmakers, criticizing some conservatives for being hardhearted toward the poor and disabled. He had no regrets, he said. "This has had a very significant impact on people who have fundamentally really struggled and lived in the shadows,'' he said.
It is an open question how expanding Medicaid benefits as generously as the Affordable Care Act allows, to adults earning up to 138 percent of the poverty level, could be paid for without increased taxes and Medicare cost reductions also created by the health care law.
Mr. Kasich said he was working on his own replacement for Obamacare but did not offer specifics. "I'm in favor of repealing Obamacare," he repeated. "That's all I can tell you.''
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(The Learning Network)
June 28, 2012 Thursday
Supreme Court Rules on Health Care
BYLINE: DANIEL E. SLOTNIK
SECTION: EDUCATION
LENGTH: 246 words
HIGHLIGHT: The Supreme Court left standing the basic provisions of the Obama administration's health care overhaul that was passed by Congress.
WHAT major decision did the Supreme Court announce?
WHAT provisions of the Affordable Care Act did the court support? WHAT provisions did the justices reject?
WHAT groups favor the law?
WHAT groups are opposed to it?
WHEN did the court hear arguments about the law?
WHEN was the last decision of this magnitude?
WHERE did challenges to the law arise?
WHO created the law?
WHO has vowed to repeal it, if he is elected?
WHO ruled in favor of the law, despite his usual conservative political stance?
WHY has the Affordable Care Act created such contention?
WHY do many conservatives consider the mandate to buy insurance, a pillar of the law, an infringement of personal liberty?
WHY did Justice Antonin Scalia compare the mandate with buying broccoli?
HOW did the court rule the Affordable Care Act constitutional?
HOW could the law impact life in the United States, and the medical industry?
Related: the Supreme Court's ruling; related posts on the ruling'simpact on the election and the reaction on Capitol Hill; and our lessons "Before the Law: Understanding the Supreme Court Case on the Affordable Care Act" and "10 Ways to Study the U.S. Supreme Court With The New York Times."
On the Bench? Vetting Supreme Court Nominee Elena Kagan
When Should Juvenile Offenders Receive Life Sentences?
Fill-In | A Pat on the Head of State, Immortalized
The Vice President as a Teenager: A Lesson a la 'Saturday Night Live'
Before the Law: Understanding the Supreme Court Case on the Affordable Care Act
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The New York Times
December 8, 2016 Thursday 00:00 EST
Cures Act Gains Bipartisan Support That Eluded Obama Health Law;
Congressional Memo
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1221 words
HIGHLIGHT: The 21st Century Cures Act, a bill that sailed through Congress with overwhelming support from both parties, stands in contrast to the looming fight over the Affordable Care Act.
WASHINGTON - With self-congratulatory zeal and smiles all around, huge bipartisan majorities in Congress have just passed legislation to speed the discovery of cures for killer diseases. At the same time, Republican leaders have been devising a strategy to undo the Affordable Care Act, which has done more than any law in a generation to treat people with those diseases.
"It is a real contradiction," said Dr. Otis W. Brawley, the chief medical officer at the American Cancer Society.
In recent years, few major bills have commanded as much support as the 21st Century Cures Act, which sailed to passage by votes of 392 to 26 in the House on Nov. 30, and 94 to 5 in the Senate a week later. Once it is signed by President Obama on Tuesday, as the White House has said it will be, the law will allow for money to be pumped into biomedical research and speed the approval of new drugs and medical devices. It also includes provisions to improve mental health care and combat opioid abuse.
"This is the most significant legislation passed by this Congress," the Senate majority leader, Mitch McConnell of Kentucky, said on Thursday. By contrast, he once referred to the 2010 health law as "the single worst piece of legislation that has been passed in the last half-century."
Ellen V. Sigal, the chairwoman of Friends of Cancer Research, an advocacy group, said "there's a disconnect" between efforts to pass the Cures Act and to repeal the Affordable Care Act.
"Most people voting and lobbying on Capitol Hill have health insurance," Ms. Sigal said. "Intellectually, they may know that some people are suffering without insurance. But do they have empathy? Those who are insured may not emotionally understand what it is like for those who are not insured. We live in our own bubble."
Lawmakers have their own explanations.
For one thing, the two health care efforts vastly differ in size. At a cost of $6.3 billion, the Cures Act is not small, but the Affordable Care Act cost hundreds of billions of dollars and affected every facet of medicine - from insurance coverage to delivery of care. It was bound to be more difficult to enact.
The Republican authors of the Cures Act - Representative Fred Upton of Michigan and Senator Lamar Alexander of Tennessee - went to great lengths to work closely with Democrats, led by Representative Diana DeGette of Colorado and Senator Patty Murray of Washington. The cooperation paid off.
"We had bipartisan buy-in from Day 1," Ms. DeGette said.
By contrast, the Affordable Care Act was adopted in 2010 without a single Republican vote - either because, as Democrats have said, Republicans refused to cooperate; or, as Republicans have said, because it was jammed down their throats.
"We have been like the Hatfields and McCoys ever since, shooting each other," Mr. Alexander said.
Mr. Alexander, deeply frustrated by his dealings with the Obama White House in 2010, learned from that experience. "The next administration or the next Congress will not be repealing the Cures Act," he said, "because we have taken the time to work out our differences, and create a consensus of support."
The American Cancer Society supported both the Affordable Care Act and the current biomedical research bill, and sees the two efforts as intertwined.
"The Cures bill includes incredibly important reforms to get treatments to people faster," said Dr. Brawley, the top medical officer at the society. But he added, "We need to get those treatments to all people faster," and he emphasized the word "all."
The surge in spending on medical research will almost surely lead to new treatments, which could include some extraordinarily expensive drug therapies. To get such treatments, patients would need to have not just insurance, but good insurance coverage. (Some drug companies offer prescription assistance programs to help defray the costs.) A repeal of the Affordable Care Act could leave millions without access to the benefits of the biomedical research bill, Democrats have said.
Another factor in passage of the Cures Act was the relentless advocacy of Dr. Francis S. Collins, director of the National Institutes of Health, who helped lawmakers appreciate the possibility of a golden age of medicine - with an artificial pancreas for diabetics, a vaccine for AIDS and the use of stem cells to repair damaged heart tissue.
Representative Steve Cohen, Democrat of Tennessee, said: "My secretary of defense is Francis Collins, because the true enemy of each and every one of us isn't somebody in South Korea or somebody in Iran or ISIS. It's cancer, it's Alzheimer's, it's AIDS, it's diabetes, it's heart disease - all those dreadful, awful diseases that N.I.H. is looking for cures for."
Even as Congress wrapped up approval of the Cures Act this week, Republicans were having serious discussions about how to repeal and replace the Affordable Care Act without interrupting coverage for the newly insured. Republicans say they feel an obligation to move fast, because the law is crushing many families and small businesses with high costs.
Democrats say some Republicans want to repeal the president's signature legislative achievement just because it is called Obamacare. It would be "a poke in his eye politically," said Senator Tim Kaine, Democrat of Virginia, who warned that a repeal could be "catastrophic to tens of millions of Americans."
The Cures Act would also increase access to mental health care, which has been a bipartisan goal since the fatal shootings in 2012 of 20 children and six adults at Sandy Hook Elementary School in Newtown, Conn.
But Representative Frank Pallone Jr., Democrat of New Jersey, said the benefits of the mental health provisions "will be far outweighed by the catastrophic harm caused by individuals with mental illness if the Republicans move forward with their radical plans to repeal the Affordable Care Act."
Sponsors of the Cures Act toured the country, visited clinics, held hearings and listened to patients who recounted their struggles with cancer, Alzheimer's and dozens of other diseases. Patients and their well-organized advocacy groups proved to be more effective than the uninsured in lobbying Congress.
In debates on the Affordable Care Act, lawmakers have continually fought over the proper role of the federal government.
Republicans see the need for a federal role in conducting research and regulating drugs, but not in regulating the details of health insurance. Under the 2010 law, they have said, the Obama administration has issued so many regulations, bulletins, official policy statements and informal "guidance documents" that not even federal officials can keep track of them all.
Democrats have said the federal standards are needed to guarantee universal access to "essential health benefits," and to prevent insurers from discriminating against those who are sick.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
PHOTO: Members of the House and Senate on Thursday after signing the 21st Century Cures Act. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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February 4, 2017 Saturday
Late Edition - Final
Health Care Law Sign-Ups Dip Amid Uncertainty and Attacks by Trump
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 1012 words
WASHINGTON -- The number of people who signed up for health insurance in the federal marketplace that serves most states dipped this year to 9.2 million, the Trump administration said Friday, as consumers struggled with confusion over the future of the Affordable Care Act.
That represents a decline of more than 4 percent from the total of 9.63 million people who signed up through HealthCare.gov at this time last year.
The numbers do not include activity in the 11 states that run their own online marketplaces under the Affordable Care Act, former President Barack Obama's signature health care law. State reports suggest that they have signed up about three million people.
Veterans of the Obama administration said President Trump's opposition to the health law and his efforts to undermine it had taken a toll. People may also have been influenced by signals from Congress that the law would soon be repealed. And some consumers may have been put off by the termination of their health plans, which was caused by an exodus of major insurers from the market in many states.
Just before leaving office, the Obama administration reported that sign-ups through HealthCare.gov were running slightly ahead of the number at the same time last year, with 8.8 million as of Jan. 14.
''Trump's sabotage worked,'' said Ben Wakana, who was a spokesman for Sylvia Mathews Burwell, the secretary of health and human services under Mr. Obama. ''We were on track to exceed last year's total. We expected a million people to sign up on the federal exchange in the final week of the open enrollment period.''
Still, the numbers present a challenge to Republicans who are struggling to repeal the law that allowed those millions to purchase insurance plans -- and who have promised not to displace anyone covered by it.
The fourth annual open enrollment season began Nov. 1 and ended Tuesday, 11 days after Mr. Trump took office.
The Trump administration scaled back publicity and advertising in the final days of the open enrollment period. Mr. Trump also issued a broadly worded executive order that directed federal officials to waive or delay any provision of the Affordable Care Act that would impose ''a cost, fee, tax, penalty or regulatory burden on individuals.''
The order, issued within hours of Mr. Trump's inauguration on Jan. 20, did not specify what actions would be taken. But lawyers and health policy experts read it as an indication that the government might not enforce the federal requirement for people to have health insurance or pay a tax penalty.
Mr. Trump has described the Affordable Care Act as ''a complete and total disaster'' and has said he wants to replace it with better, cheaper coverage ''for everybody,'' but he has not offered a plan to achieve that goal.
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, who is trying to draft a replacement for the law, said that ''today's numbers failed to keep pace with last year's.'' In addition, he suggested, some people who signed up will not pay their premiums and will therefore not have coverage this year.
''Either way,'' Mr. Hatch said, ''enrollment numbers are down, and costs are up.''
That response was predicted by Representative Nancy Pelosi of California, the House minority leader and an architect of the law.
''Now, Republicans will cynically point to the dip in enrollment they caused, declare the Affordable Care Act broken and move to steal the affordable health coverage of every American,'' she said. ''Meanwhile, in states committed to delivering affordable health coverage to their residents, enrollment in the Affordable Care Act's marketplaces has surged.''
''Democrats will continue to stand our ground to ensure that every American has access to affordable health coverage,'' she added.
Enrollment reports from the Obama administration were invariably upbeat, saying the numbers showed that people needed and wanted insurance under the Affordable Care Act.
The first report from the Trump administration struck a different tone.
''Obamacare has failed the American people, with one broken promise after another,'' Matt Lloyd, a spokesman for the Department of Health and Human Services, said Friday. ''Premiums in the A.C.A. marketplace have increased 25 percent while the number of insurers has declined 28 percent over the past year.''
Of the 9.2 million people who signed up through HealthCare.gov, one-third were new to the federal marketplace, and two-thirds were returning customers. The individual insurance market is in constant flux. With changes in income and employment, consumers may gain or lose coverage from Medicaid, employers and other sources of insurance.
The Obama administration predicted in October that 13.8 million people would sign up for coverage in the enrollment period that ended this week. The total appears likely to fall short of that goal.
Leslie Dach, a former Obama administration official who is trying to preserve the health law as a leader of the Protect Our Care Coalition, said, ''Enrollment was a success, and it would have been even higher without the Trump administration's efforts to suppress enrollment.'' Despite those efforts, he said, ''Americans continued to enroll in the final weeks, proving that there is considerable demand for quality and affordable coverage.''
Several states that run their own insurance exchanges appear to have done better than the federal marketplace. In New York, 908,200 people signed up through the state marketplace for either a qualified health plan or the ''basic health program'' authorized by the Affordable Care Act for low-income people. That represents an increase of 39 percent.
Under the Obama administration, enrollment in marketplace insurance plans was consistently lower than the levels originally projected by the Congressional Budget Office, in part because consumers were more likely to get and keep employer-sponsored insurance.
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URL: http://www.nytimes.com/2017/02/03/us/politics/affordable-care-act-obama-care-sign-up.html
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April 3, 2013 Wednesday
Small Companies and the Affordable Care Act
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 661 words
HIGHLIGHT: The Affordable Care Act may benefit medium-size companies by making it costly for their smaller competitors to expand, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Small businesses have spoken out against the Affordable Care Act, but medium-size businesses, customers and taxpayers may be the ones ultimately harmed.
Beginning next year, the Affordable Care Act will penalize employers that fail to offer health insurance to their employees. Because small employers are especially unlikely to offer health insurance (see Table 3 in this paper from the Congressional Budget Office), and large businesses are likely to avoid the penalties because they already offer insurance, the penalties seem like an attack on small business.
But the Affordable Care Act simultaneously rewards employees at small companies by heavily subsidizing their purchases of health insurance on the exchanges created by the law. Because employees cannot take the subsidies with them if they switch to a large company offering health insurance, the subsidies are, in effect, subsidies to the small businesses themselves, helping them compete more cheaply in the market for employees.
Employees at the smallest companies, with fewer than 50 employees, are eligible to receive the subsidies, even though their employers are exempt from the penalties.
Indeed, some medium-size businesses that currently offer health insurance say they find the smaller company "penalty plus subsidy" combination attractive and plan to drop their health insurance plans in order to partake in it, too, even though their participation will entail a penalty.
The Affordable Care Act also created tax credits for small business that are already available. These credits perhaps have too many strings attached to be attractive to employers, because only 770,000 employees (in an economy with more than 130 million) worked for employers claiming the credit in 2010 (see Page 9 of this report from the Government Accountability Office). The Affordable Care Act also promised to provide small-business employees a choice of health plans, but implementation of that plan has been pushed back until 2015.
Many small businesses are not as good with bureaucracy and red tape as large businesses are - that's one reason they did not offer health insurance in the first place. The employee subsidies coming online next year are pretty complicated, as evidenced by the 21-page application that must be completed by each employee, and the fact that any one year's subsidy has to be estimated based on historical employee data, advanced from the Internal Revenue Service to the insurer, and then later reconciled when the employee's family income for the year can be fully documented.
I suspect that large businesses will have human resource personnel dedicated to helping company employees complete the application and obtain and accurately reconcile the subsidy to which they are entitled. Employees at smaller business may have to fend for themselves.
We also have to remember that businesses compete for customers and for employees. A business that experiences a little direct harm from the act may benefit on the whole because competitors are harmed more. This is especially true because of the heavy penalty the law puts on businesses that expand from 49 to 50 employees: that one hire will cost the employer $40,000 annually in penalties, on top of that employee's usual salary and benefits.
Thus, the type of company that may benefit the most from the law is not necessarily large or small but a company with small competitors that have been looking for opportunities to expand their market share, and in the process bring the number of their employees to more than 49.
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
From Physician Glut to Physician Shortage
Health Care: Solidarity vs. Rugged Individualism
Awaiting the Supreme Court's Health Care Ruling
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November 29, 2016 Tuesday 00:00 EST
Tom Price, Health Dept. Nominee;
Letter
SECTION: OPINION
LENGTH: 225 words
HIGHLIGHT: A business professor rebuts Dr. Price's criticisms of the Affordable Care Act.
To the Editor:
Re "Fierce Critic of Health Care Law Said to Be Pick for Health Dept." (front page, Nov. 29):
Representative Tom Price, an orthopedic surgeon from Georgia, is expected to be nominated as secretary of health and human services. You note that in the 2009 debate over the Affordable Care Act, Dr. Price called the federal government "stifling and oppressive."
It is true that the act does establish requirements for health insurers. Among other things, insurers cannot deny coverage to people with pre-existing conditions or charge them more than others, and they may not establish annual or lifetime limits.
While Dr. Price may consider those "stifling and oppressive," most Americans would choose the Affordable Care Act's protections over the conditions that existed before the law's passage.
Dr. Price's "most frequent objection to the law is that it interferes with the ability of patients and doctors to make medical decisions." Yet there is absolutely no evidence of that.
We may not agree on policy preferences, but if we could at least begin the policy discussion from a foundation of fact, that would be a small amount of progress.
STEPHEN M. DAVIDSON
Boston
The writer is a professor at the Questrom School of Business, Boston University, and the author of "A New Era in U.S. Health Care: Critical Next Steps Under the Affordable Care Act."
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May 1, 2013 Wednesday
Uncertainty Still Clouds Health Care Law
BYLINE: MICAH COHEN
SECTION: US; politics
LENGTH: 455 words
HIGHLIGHT: As concerns arise about implementing the Affordable Care Act, even among its supporters, the White House has another worry: the law is still not well liked or well understood.
Three years after President Obama signed the health care reform law, there are concerns that the process of implementing it will be rocky. Even some of the law's supporters are worried.
Perhaps more troubling for the White House, the Affordable Care Act is still not well liked or well understood. The Obama administration had hoped that over time, the legislation would gain enough support to help smooth over the rough patches of putting it into practice. Instead, public opinion has remained mostly static: a plurality of Americans still disapprove of the law, and a substantial portion of the public remains uncertain about what it says, according to recent polls.
There is even confusion about whether the health care law is still, in fact, law. A Kaiser Family Foundation survey [PDF] conducted in April found that 41 percent of American adults did not know that the Affordable Care Act remains the law of the land. A separate tracking survey conducted in April by Kaiser, which has done far more surveys on health care than any other polling organization, found that roughly half of American adults said they did not have enough information about the law to understand how it will affect them.
The tracking poll found that there had actually been an increase in the percentage of American adults with no opinion about the health care law.
Among those who do have an opinion, more people still regard the health care law negatively than positively, according to a series of recent polls. In fact, the law's net approval numbers stand basically where they did when it was passed.
One reason the Obama administration might still be optimistic is that while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law.
For example, Kaiser has found that about 70 percent of adults support providing financial assistance to low- and moderate-income Americans who do not have employer-provided health insurance, and also that about 70 percent support health insurance exchanges and the elimination of out-of-pocket costs for many preventive services - both elements of the health care law.
Once those benefits become realities, the percentage of Americans who approve of the law may rise. But if the law's rollout is messy, there may be a dip in approval before it has a chance to become more popular.
As Obama Faces Crises Abroad, His Foreign Policy Approval Is Down
What Does Public Support in Obama's Second Inaugural Speech?
Polls Show Below-Average Post-Election Approval Bounce for Obama
Sept. 23: Does Omaha Matter?
July 18: New Polls, but Little Change in Horse Race
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June 26, 2015 Friday
6 Q's About the News | Supreme Court Allows Nationwide Health Care Subsidies
BYLINE: MICHAEL GONCHAR
SECTION: EDUCATION
LENGTH: 272 words
HIGHLIGHT: What rationale did Chief Justice Roberts give for the court’s decision?
Note: We're experimenting with a new format for this feature. Tell us what you think!
The June 25 article "Supreme Court Allows Nationwide Health Care Subsidies" begins:
The Supreme Court ruled on Thursday that President Obama's health care law allows the government to provide nationwide tax subsidies to help poor and middle-class people buy health insurance, a sweeping vindication that endorsed the larger purpose of Mr. Obama's signature legislative achievement.
Read the entire article and answer the following questions. Support your responses using evidence from the text.
1. What is the Affordable Care Act?
2. What issue was the Supreme Court deciding this term related to the Affordable Care Act, and what did the court decide?
3. What rationale did Chief Justice Roberts give for the court's decision?
4. Why did Justice Antonin Scalia dissent?
5. How was this case different from the first case the Supreme Court decided in 2012 concerning the Affordable Care Act?
6. The Times Editorial Board writes, "The Supreme Court Saves Obamacare, Again." Do you believe the court made the right choice, in two separate decisions, to save the Affordable Care Act? Why?
Going Further
The Supreme Court has issued many more decisions in 2015 than in just King v. Burwell. Use the Times infographic "Major Supreme Court Cases in 2015" to choose one additional court decision from this term. Find out what the court decided and what was at stake. Then weigh in on whether you think the court made the right decision, and explain your reasoning.
Related
Teaching Resource | Ways to Study the U.S. Supreme Court With The New York Times
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July 20, 2011 Wednesday
Is Dividing a Company the Way to Beat the Affordable Care Act?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 988 words
HIGHLIGHT: There's a lot of interest, but it probably won't work, according to several tax and benefit lawyers.
That's one notion that seems to be circulating among small-business owners and their advisers lately. Consultants at McKinsey & Company floated the suggestion as part of their controversial report on employer views of health insurance. And in The Times's coverage of that report, Milt Freudenheim interviewed a small-business owner who said he was hoping to "game the system." The owner, Gerry Harkins, who is also chairman of the National Federation of Independent Business's Georgia State Leadership Council, said he might split his Atlanta-based construction company into two smaller companies to evade the overhaul's employer mandate, specifically the penalties on companies that fail to offer affordable health insurance to employees.
Unfortunately for Mr. Harkins (who did not return a call from The Agenda seeking an elaboration of his comments), the authors of the Affordable Care Act are one step ahead of him, according to several tax and benefit lawyers contacted by The Agenda. The authors included a provision that basically adopts parts of the Employee Retirement Income Security Act of 1974 that say any group of companies under common control are to be treated as a single company. Common control is defined as the same five or fewer people owning at least 80 percent of the companies, according to Al Martin, a tax lawyer at the Kansas City law firm Lathrop & Gage. Spouses and children are generally considered one owner, according to Mr. Martin.
No doubt this will make it difficult for people like Mr. Harkins to game the system. "You're going to wind up changing economic relationships if you avoid the rules," he said. "You've got to change ownership structure."
"The idea that that would be an easy thing to do would be hard for me to believe," added Jon Staudt, a tax lawyer with Belin McCormick in Des Moines. "People have been trying to avoid the E.R.I.S.A. law so that they could have separate pension plans, for example, pretty unsuccessfully for 36 years."
The McKinsey consultants, for their part, had other reasons for proposing a split. The thrust of their advice is to find ways to wean lower-wage employees off employer-sponsored coverage while keeping higher-wage employees, who won't be eligible for subsidies, insured.
Until the Affordable Care Act, federal law was a bit schizophrenic when it came to group health insurance plans for 50 or more people. A company that funded its own health insurance plan - a strategy that often makes financial sense for companies with several hundred participants - was subject to an antidiscrimination law that banned those plans from offering looser eligibility requirements or better benefits to top executives.
"The basic rule is you can do anything you want, but if the plan is self-funded, and if the effect of it is that the highly paid get the Cadillac deal and everybody else gets the Ford, that's not going to work," said Charles Wolfe, a lawyer at the Chicago law firm Vedder Price, and a co-chairman of an employee benefits committee of the American Bar Association. "The executives are going to get taxed."
There was a loophole, however: because group plans insured by a third party (like an insurance company) are regulated by the states, they weren't subject to federal discrimination laws. The solution for big companies, said Mr. Wolfe, was to self fund health insurance for the rank and file and buy a separate insured plan for the executives.
Now the Affordable Care Act is poised to close that loophole by applying the same antidiscrimination rules for self-funded plans to insured plans. (Because the regulations have not been written, the Internal Revenue Service is not yet enforcing this provision of the new law.) One option McKinsey proposes is to split the company into two separate entities, one with company managers and others who would get employer-sponsored insurance and the other for employees who would get no insurance. The company without insurance would have to pay the mandate penalty on those employees, and perhaps even additional compensation, but that could still be cheaper than buying their coverage.
Ah, but beware of free advice, which, as they say, is often worth what you pay for it. Here again, Congress linked the antidiscrimination law for self-funded plans to E.R.I.S.A.'s common-control provision. And the section of the Affordable Care Act that extends the discrimination ban to insured plans explicitly ties the new ban to those same common-control rules. McKinsey's suggestion "strikes me as a bit odd, in the sense that I don't think it will be possible for a company to keep its corporate or senior management in one company and the rest of its work force in another company and still provide tax-advantaged benefits to the senior management," said Philip Mowrey, one of Mr. Wolfe's partners at Vedder Price.
A McKinsey spokeswoman said the firm had no comment.
The penalty assessed under the Affordable Care Act, Mr. Mowrey also noted, was stiff: $100 a day multiplied by every employee discriminated against.
At least in theory, that is. According to Mr. Mowrey, the discrimination regulations for self-funded plans have never really been enforced, because they don't address very well the new types of health care plans that have been developed since the regulations were adopted in 1981. "It was sort of a moribund law," he said. With the expansion created by the Affordable Care Act, he says, it's clear that the I.R.S. is committed to implementing the bans for both kinds of insurance plans.
That means the only way a business owner will be able to beat the health care law by splitting a company into two will be by selling one, or most of one, of the resulting pieces.
Doing the Math on Employer Health Insurance
Debating Whether Businesses Will Continue to Offer Health Insurance
How the Health Care Law Affects Your Business
Looking to the Affordable Care Act For Help
Is the Health Care Plan a Good Thing?
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December 9, 2016 Friday
Late Edition - Final
Finding Rare Common Ground in Health Care's Future
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; CONGRESSIONAL MEMO; Pg. 21
LENGTH: 1173 words
WASHINGTON -- With self-congratulatory zeal and smiles all around, huge bipartisan majorities in Congress have just passed legislation to speed the discovery of cures for killer diseases. At the same time, Republican leaders have been devising a strategy to undo the Affordable Care Act, which has done more than any law in a generation to treat people with those diseases.
''It is a real contradiction,'' said Dr. Otis W. Brawley, the chief medical officer at the American Cancer Society.
In recent years, few major bills have commanded as much support as the 21st Century Cures Act, which sailed to passage by votes of 392 to 26 in the House on Nov. 30, and 94 to 5 in the Senate a week later. Once it is signed by President Obama on Tuesday, as the White House has said it will be, the law will allow for money to be pumped into biomedical research and speed the approval of new drugs and medical devices. It also includes provisions to improve mental health care and combat opioid abuse.
''This is the most significant legislation passed by this Congress,'' the Senate majority leader, Mitch McConnell of Kentucky, said on Thursday. By contrast, he once referred to the 2010 health law as ''the single worst piece of legislation that has been passed in the last half-century.''
Ellen V. Sigal, the chairwoman of Friends of Cancer Research, an advocacy group, said ''there's a disconnect'' between efforts to pass the Cures Act and to repeal the Affordable Care Act.
''Most people voting and lobbying on Capitol Hill have health insurance,'' Ms. Sigal said. ''Intellectually, they may know that some people are suffering without insurance. But do they have empathy? Those who are insured may not emotionally understand what it is like for those who are not insured. We live in our own bubble.''
Lawmakers have their own explanations.
For one thing, the two health care efforts vastly differ in size. At a cost of $6.3 billion, the Cures Act is not small, but the Affordable Care Act cost hundreds of billions of dollars and affected every facet of medicine -- from insurance coverage to delivery of care. It was bound to be more difficult to enact.
The Republican authors of the Cures Act -- Representative Fred Upton of Michigan and Senator Lamar Alexander of Tennessee -- went to great lengths to work closely with Democrats, led by Representative Diana DeGette of Colorado and Senator Patty Murray of Washington. The cooperation paid off.
''We had bipartisan buy-in from Day 1,'' Ms. DeGette said.
By contrast, the Affordable Care Act was adopted in 2010 without a single Republican vote -- either because, as Democrats have said, Republicans refused to cooperate; or, as Republicans have said, because it was jammed down their throats.
''We have been like the Hatfields and McCoys ever since, shooting each other,'' Mr. Alexander said.
Mr. Alexander, deeply frustrated by his dealings with the Obama White House in 2010, learned from that experience. ''The next administration or the next Congress will not be repealing the Cures Act,'' he said, ''because we have taken the time to work out our differences, and create a consensus of support.''
The American Cancer Society supported both the Affordable Care Act and the current biomedical research bill, and sees the two efforts as intertwined.
''The Cures bill includes incredibly important reforms to get treatments to people faster,'' said Dr. Brawley, the top medical officer at the society. But he added, ''We need to get those treatments to all people faster,'' and he emphasized the word ''all.''
The surge in spending on medical research will almost surely lead to new treatments, which could include some extraordinarily expensive drug therapies. To get such treatments, patients would need to have not just insurance, but good insurance coverage. (Some drug companies offer prescription assistance programs to help defray the costs.) A repeal of the Affordable Care Act could leave millions without access to the benefits of the biomedical research bill, Democrats have said.
Another factor in passage of the Cures Act was the relentless advocacy of Dr. Francis S. Collins, director of the National Institutes of Health, who helped lawmakers appreciate the possibility of a golden age of medicine -- with an artificial pancreas for diabetics, a vaccine for AIDS and the use of stem cells to repair damaged heart tissue.
Representative Steve Cohen, Democrat of Tennessee, said: ''My secretary of defense is Francis Collins, because the true enemy of each and every one of us isn't somebody in South Korea or somebody in Iran or ISIS. It's cancer, it's Alzheimer's, it's AIDS, it's diabetes, it's heart disease -- all those dreadful, awful diseases that N.I.H. is looking for cures for.''
Even as Congress wrapped up approval of the Cures Act this week, Republicans were having serious discussions about how to repeal and replace the Affordable Care Act without interrupting coverage for the newly insured. Republicans say they feel an obligation to move fast, because the law is crushing many families and small businesses with high costs.
Democrats say some Republicans want to repeal the president's signature legislative achievement just because it is called Obamacare. It would be ''a poke in his eye politically,'' said Senator Tim Kaine, Democrat of Virginia, who warned that a repeal could be ''catastrophic to tens of millions of Americans.''
The Cures Act would also increase access to mental health care, which has been a bipartisan goal since the fatal shootings in 2012 of 20 children and six adults at Sandy Hook Elementary School in Newtown, Conn.
But Representative Frank Pallone Jr., Democrat of New Jersey, said the benefits of the mental health provisions ''will be far outweighed by the catastrophic harm caused by individuals with mental illness if the Republicans move forward with their radical plans to repeal the Affordable Care Act.''
Sponsors of the Cures Act toured the country, visited clinics, held hearings and listened to patients who recounted their struggles with cancer, Alzheimer's and dozens of other diseases. Patients and their well-organized advocacy groups proved to be more effective than the uninsured in lobbying Congress.
In debates on the Affordable Care Act, lawmakers have continually fought over the proper role of the federal government.
Republicans see the need for a federal role in conducting research and regulating drugs, but not in regulating the details of health insurance. Under the 2010 law, they have said, the Obama administration has issued so many regulations, bulletins, official policy statements and informal ''guidance documents'' that not even federal officials can keep track of them all.
Democrats have said the federal standards are needed to guarantee universal access to ''essential health benefits,'' and to prevent insurers from discriminating against those who are sick.
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URL: http://www.nytimes.com/2016/12/08/us/politics/cures-act-health-care-congress.html
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GRAPHIC: PHOTO: Members of the House and Senate on Thursday after signing the 21st Century Cures Act. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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November 21, 2012 Wednesday
Employer-Provided Health Insurance and the Market
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 818 words
HIGHLIGHT: As the Affordable Care Act takes hold, some employers will use their health insurance coverage to attract workers, while others will drop the coverage and use higher pay as the lure, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The future of employer-provided health insurance is better considered together with the future of total employee compensation, both cash and fringe benefits like health insurance. From that perspective, the likelihood that most employers will continue to offer health insurance is not necessarily good news for employees.
The Patient Protection and Affordable Care Act, President Obama's initiative, offers large health-insurance subsidies to the majority of the population beginning in 2014, but only if their employer does not offer affordable insurance. The subsidies are frequently much larger than the subsidies coming through the tax exclusion of employer-provided health insurance.
Some economists are predicting that eligible employees, especially those in line for the largest subsidies, will prefer employers who do not offer affordable insurance. As a result, they say, many more employers will not offer insurance.
Others have different expectations, pointing out that employers dropping insurance will pay penalties and throw away the tax exclusion for their employees who are not subsidy-eligible (typically the ones who earn more). Moreover, perhaps because people are comfortable with their existing coverage even if it is not subsidized, employer coverage did not decline in Massachusetts when it began a similar plan (by my estimate, only 5 percent of the people in Massachusetts who could get subsidized individual-market insurance actually receive it, largely because they have coverage through the employer of the head of the household or that person's spouse). Note that Massachusetts has lower subsidies and a narrower eligible population than the Affordable Care Act and lower employer penalties for dropping coverage.
How many employers will drop their coverage when the new health care law gets under way? The answer makes for a nice headline, but that's the wrong question. Would it be so bad if many employers dropped their coverage but replaced it with huge cash raises? Or would it be so good if every employer continued to offer coverage but required employees to take big pay cuts?
All sides agree that some otherwise subsidy-eligible employees will work for employers that keep their coverage, and other subsidy-eligible employees will work for employers that drop it. Market forces must be considered, because some employees will be moving between these two types of employers.
Low-income employees will ultimately cost less to employers without coverage (or without "affordable" coverage; the important issue is that their low-income employees are subsidy-eligible) than they cost to employers with coverage. If they didn't, low-income employees would be better off at employers without coverage and would line up to work there. Meanwhile, the employers with coverage would find it more difficult to retain and attract low-income employees. That situation defies supply and demand.
Another way to see the same result: by getting low-income employees at lesser cost, employers without coverage can, without going out of business, compete aggressively for the high-income employees who are considering positions that offer coverage.
By the same logic, high-income employees will cost more to employers without coverage than they do to employers with coverage. Thus, high-income employees will lose one way or another -- either they will lose their tax exclusion because their employer eliminates coverage or they will see their cash compensation fall below what it would have been without the Affordable Care Act.
At the same time, the low-income employees will enjoy the subsidy either way: either their employer drops coverage, in which case they receive the subsidy directly, or their employer increases their compensation above what it would be without the Affordable Care Act to attract them from the employers without coverage. Tax economists will recognize this as the Harberger model applied to the Affordable Care Act; international economists will recognize it as the Heckscher-Ohlin model.)
The same sorts of market competition will ultimately prevent most employers from dropping their coverage and thereby incurring the penalties. Employers keeping coverage will raise the pay of subsidy-eligible employees and get by with fewer of them. Those who remain will typically not want to leave for no-coverage employers because doing so would cut their pay. The same employers will hire a few more high-income employees at lesser pay, because for those employees, the alternative is a no-coverage employer.
From Physician Glut to Physician Shortage
Awaiting the Supreme Court's Health Care Ruling
Medicaid Expansion and Jobs
The Wyden-Ryan Plan: Deja Vu All Over Again
Social Insurance and Individual Freedom
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March 8, 2017 Wednesday
Late Edition - Final
Law Took Months to Draft; Repeal May Be Much Swifter
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 909 words
WASHINGTON -- In June 2009, House Democratic leaders unveiled the first draft of legislation that would ultimately become the Affordable Care Act. A month later, three House committees began formally drafting the bill ahead of a House vote that came well into the fall, after the summer heat had dissipated and the leaves had begun to change.
On Wednesday, the House Ways and Means Committee and the Energy and Commerce Committee will formally mark up legislation to repeal and replace the act -- less than 48 hours after Republicans unveiled the bill to the public. If all goes according to plan, the House will vote within a few weeks, and the Senate will take up the legislation before its spring recess begins on April 7.
Republicans excoriated Democrats for rushing passage of the Affordable Care Act -- President Barack Obama's landmark health law -- blasting ''back-room deals'' and cheering on the nascent Tea Party movement, with its hostile chant ''Read the bill, read the bill.'' But Republicans have adopted a much more aggressive timetable for repealing the law and remaking Medicaid, the health program for more than 70 million low-income people.
''The difference between 2009 and 2017 is like black and white,'' said former Senator Max Baucus of Montana, one of the chief architects of the Affordable Care Act, who spent countless hours in hearings and negotiations on the legislation as chairman of the Senate Finance Committee. ''It's a chasm. There's no comparison.''
On Monday evening, House Republicans unveiled their proposals to undo the law, signed by Mr. Obama in March 2010. The two House committees plan to start debating, amending and voting on the legislation on Wednesday. By week's end, they expect to finish this ritual, known as a markup.
Speaker Paul D. Ryan said the House would pass the repeal bill within a few weeks, and the Senate majority leader, Mitch McConnell, Republican of Kentucky, said that if the House kept to that timetable, the legislation ''will be on the agenda here in the Senate'' before the spring recess.
In comparison with the pace of work on the Affordable Care Act, that is lightning fast.
''We don't know how much it will cost, and we don't know if this bill will make health care more affordable for Americans,'' Senator Mike Lee, Republican of Utah, said on Tuesday. ''This is exactly the type of back-room dealing and rushed process that we criticized Democrats for.''
Representative Jim Jordan, a conservative Republican from Ohio who objects to major provisions of the bill devised by House Republican leaders, said, ''The American people don't want us to rush this thing.''
In June and July 2009, with Democrats in charge, the Senate health committee spent nearly 60 hours over 13 days marking up the bill that became the Affordable Care Act. That September and October, the Senate Finance Committee worked on the legislation for eight days -- its longest markup in two decades. It considered more than 130 amendments and held 79 roll-call votes.
The full Senate debated the health care bill for 25 straight days before passing it on Dec. 24, 2009.
''After years of howling at the moon about Democrats rushing through the Affordable Care Act,'' said Senator Chuck Schumer of New York, the Democratic leader, Republicans are now racing to pass the repeal bill because ''they don't want anyone to know what's in the bill.''
Democrats complained that the Republicans were rushing to approve a repeal bill without hearing from consumers, health care providers, insurance companies or state officials -- and without having estimates of the cost or the impact on coverage from the Congressional Budget Office.
Representative Greg Walden, Republican of Oregon and chairman of the Energy and Commerce Committee, denied that Republicans were cutting corners to speed approval of their repeal bill.
''In fact,'' he said on Tuesday, ''the bill went online live for the entire American people, all of you, all of us to read, all of our colleagues to read, at 6 o'clock last night. It's not that much to get through. It's pretty well understood.''
The Republicans' bill is indeed much shorter than the Affordable Care Act. With one paragraph of their bill, they can obliterate 10 or 20 pages of the law. One of their chief goals is to eliminate detailed federal standards, like those that define the permissible value of insurance plans -- bronze, silver, gold and platinum.
Another previous complaint by Republicans seems to apply now. For years, Republicans have reminded voters that the Affordable Care Act passed without any Republican votes. If they now repeal it, they are unlikely to have a single Democrat with them.
In 2009, Democratic senators negotiated with Republicans for months in hopes of finding common ground, but Republicans now do not expect any help from Democrats.
''We're not going to do this with Democrats,'' said Senator John Cornyn of Texas, the No. 2 Senate Republican.
In remarks prepared for the Ways and Means Committee meeting on Wednesday, Representative Sander M. Levin, Democrat of Michigan, said: ''Bad process makes for bad policy. And the process we are using today is not only bad; it's reckless. Almost no time to review the bill, no hearings on the bill, no C.B.O. estimate of the cost or coverage impact -- this is legislative malpractice.''
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URL: http://www.nytimes.com/2017/03/07/us/politics/obamacare-repeal-of-health-law-republicans.html
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The New York Times
February 25, 2017 Saturday
Late Edition - Final
Ex-Kentucky Governor to Give Democrats' Reply to the President's Speech
BYLINE: By ALEXANDER BURNS
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 699 words
WASHINGTON -- Former Gov. Steve Beshear of Kentucky, a senior Democrat best known for putting the Affordable Care Act into effect in a deeply conservative state, will give his party's response to President Trump's address to Congress on Tuesday, Democratic congressional leaders announced on Friday.
In selecting Mr. Beshear, 72, Democrats opted to elevate an elder statesman from the belt of heartland states that Mr. Trump won handily, rather than highlighting one of the party's newer faces or a potential challenger to Mr. Trump in 2020.
In announcing the choice, Senator Chuck Schumer of New York, the Democratic leader, and Nancy Pelosi of California, the House minority leader, underscored Mr. Beshear's distinctive credentials as a spokesman on health care.
The party is in the middle of a major push to derail Republican efforts to repeal the Affordable Care Act, encouraging activists to swarm their members of Congress at town hall-style meetings and assailing Republican leaders for lacking a specific plan to replace the health care law.
Democratic governors gathering in Washington this weekend plan to call on Congress not to strip away health care funding from their states.
''Governor Beshear's work in Kentucky is proof positive that the Affordable Care Act works, reducing costs and expanding access for hundreds of thousands of Kentuckians,'' Mr. Schumer said in a statement.
Mr. Beshear, he added, ''knows exactly what is at risk if President Trump and congressional Republicans repeal the Affordable Care Act without a replacement.''
Ms. Pelosi described Kentucky under Mr. Beshear as ''one of the great success stories of the Affordable Care Act in delivering quality, affordable health coverage for all.''
Mr. Schumer and Ms. Pelosi also announced that Astrid Silva, an immigration activist, would give a response to Mr. Trump's address in Spanish.
Mr. Beshear, a relatively moderate Democrat who is the son of a preacher, indicated in a statement that he would also critique Mr. Trump's leadership style and discuss education and economic opportunity.
''Real leaders don't spread derision and division -- they build partnerships and offer solutions instead of ideology and blame,'' Mr. Beshear said.
But if Mr. Beshear can be expected to present an unthreatening message to voters in the political middle, it is his work on health care that has made him a national figure in the Democratic Party.
As governor, Mr. Beshear opened a state health care exchange, known as Kynect, and accepted federal money to expand Medicaid coverage in Kentucky. The number of Kentuckians without health insurance fell to 7.5 percent in 2015 from 20.4 percent in 2013, tied with Arkansas for the most dramatic plunge in the country.
Mr. Beshear has been a consistent voice of optimism about the Affordable Care Act among Democrats, and he predicted several years ago that the law would prove so popular, after being fully carried out, that it would more likely be expanded than repealed.
The law faces a far more uncertain prognosis, after Republicans won control of the White House and kept control of Congress in 2016 after campaigning on a pledge to unravel the Affordable Care Act.
Mr. Beshear's successor as governor, Matt Bevin, who is a Republican, won federal approval last fall for a plan to dismantle the Kynect exchange and move the state into the federal exchange.
But polls have shown the Affordable Care Act growing in popularity recently, during the debate over its possible demise, and Republicans in Congress are plainly struggling to make good on their vow to ''repeal and replace'' it.
Mr. Beshear's response to Mr. Trump's address will not be his first role in a presidential address to Congress. In 2014, he attended President Barack Obama's State of the Union speech as a guest of the president, who hailed his work on health care from the well of the House of Representatives.
''Kentucky's not the most liberal part of the country, but he's like a man possessed when it comes to covering his commonwealth's families,'' Mr. Obama said of Mr. Beshear.
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URL: http://www.nytimes.com/2017/02/24/us/politics/steve-beshear-to-give-democratic-response-to-trump-address.html
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October 23, 2013 Wednesday
Late Edition - Final
The Trouble at Health Care's Door
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 28
LENGTH: 464 words
To the Editor:
President Obama is correct that the chaotic debut of the Affordable Care Act's online portal is intolerable (''Obama Admits Web Site Flaws on Health Law,'' front page, Oct. 22).
The Affordable Care Act is complicated enough without handing the Republicans a gift-wrapped botched implementation procedure. President Obama and all those who work with him have very little time to get this debut straight. It's too promising a program to die of administrative incompetence!
THEODORE S. VOELKER New York, Oct. 22, 2013
To the Editor:
Re ''Contractors See Weeks of Work on Health Site'' (front page, Oct. 21):
The mind-numbing complexity of the online health insurance marketplace Web site -- 500 million lines of software code, or five times that of a large bank's computer system -- stands as a perfect metaphor for President Obama's health care law.
Had Congress simply extended Medicare to all Americans, we would have been spared the current difficulties. Instead, the Affordable Care Act turned into a Rube Goldberg-style construction in order to appease the for-profit health care industry and attract the votes of Republicans in Congress, who unanimously opposed the law anyway.
That Obamacare is now staggering under the weight of its self-imposed complexity is, in a sense, karmic justice.
FRANÇOIS FURSTENBERG Montreal, Oct. 22, 2013
To the Editor:
After spending 20-plus hours over three weeks attempting -- and failing -- to get health care coverage through the Affordable Care Act Web site, I believe that there may be a simpler solution.
As it is, to get a subsidy (tax credit) you must go through the exchange. An alternative is 1) allow direct purchase of A.C.A.-compliant policies from insurance carriers; 2) require carriers to issue a form at year end verifying the purchase and total of premiums paid; 3) submit this form and claim the subsidy (tax credit) on the individual federal tax return.
This would allow me to purchase insurance immediately, avoid the exchange and still get the benefits of the Affordable Care Act. While not a solution for everyone, it would be simple to implement and a big relief for self-employed, single parents like me who want nothing more than a clear pathway to obtain coverage.
CHARLES STANTON Jersey City, Oct. 21, 2013
To the Editor:
Suppose you go to an online bookseller and try to order the complete works of Shakespeare, only you can't because the vendor's Web site crashes. Do you then conclude that Shakespeare can't write?
We all know that would be ridiculous, so don't let people get away with the equivalent logical fallacy in the case of the Affordable Care Act. The Web site for enrollment is clearly a disaster, but that says nothing about the substance of the act itself.
JACKIE CLARE WOOD Menlo Park, Calif., Oct. 21, 2013
URL: http://www.nytimes.com/2013/10/23/opinion/the-trouble-at-health-cares-door.html
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September 27, 2013 Friday
Late Edition - Final
My State Needs Obamacare. Now.
BYLINE: By STEVE BESHEAR.
Steve Beshear, a Democrat, is the governor of Kentucky.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 23
LENGTH: 774 words
FRANKFORT, Ky. -- SUNDAY morning news programs identify Kentucky as the red state with two high-profile Republican senators who claim their rhetoric represents an electorate that gave President Obama only about a third of its presidential vote in 2012.
So why then is Kentucky -- more quickly than almost any other state -- moving to implement the Affordable Care Act?
Because there's a huge disconnect between the rank partisanship of national politics and the outlook of governors whose job it is to help beleaguered families, strengthen work forces, attract companies and create a balanced budget.
It's no coincidence that numerous governors -- not just Democrats like me but also Republicans like Jan Brewer of Arizona, John Kasich of Ohio and Rick Snyder of Michigan -- see the Affordable Care Act not as a referendum on President Obama but as a tool for historic change.
That is especially true in Kentucky, a state where residents' collective health has long been horrendous. The state ranks among the worst, if not the worst, in almost every major health category, including smoking, cancer deaths, preventable hospitalizations, premature death, heart disease and diabetes.
We're making progress, but incremental improvements are not enough. We need big solutions with the potential for transformational change.
The Affordable Care Act is one of those solutions.
For the first time, we will make affordable health insurance available to every single citizen in the state. Right now, 640,000 people in Kentucky are uninsured. That's almost one in six Kentuckians.
Lack of health coverage puts their health and financial security at risk.
They roll the dice and pray they don't get sick. They choose between food and medicine. They ignore checkups that would catch serious conditions early. They put off doctor's appointments, hoping a condition turns out to be nothing. And they live knowing that bankruptcy is just one bad diagnosis away.
Furthermore, their children go long periods without checkups that focus on immunizations, preventive care and vision and hearing tests. If they have diabetes, asthma or infected gums, their conditions remain untreated and unchecked.
For Kentucky as a whole, the negative impact is similar but larger -- jacked-up costs, decreased worker productivity, lower quality of life, depressed school attendance and a poor image.
The Affordable Care Act will address these weaknesses.
Some 308,000 of Kentucky's uninsured -- mostly the working poor -- will be covered when we increase Medicaid eligibility guidelines to 138 percent of the federal poverty level.
PricewaterhouseCoopers and the Urban Studies Institute at the University of Louisville concluded that expanding Medicaid would inject $15.6 billion into Kentucky's economy over the next eight years, create almost 17,000 new jobs, have an $802.4 million positive budget impact (by transferring certain expenditures from the state to the federal government, among other things), protect hospitals from cuts in indigent care funding and shield businesses from up to $48 million in annual penalties.
In short, we couldn't afford not to do it.
The other 332,000 uninsured Kentuckians will be able to access affordable coverage -- most with a discount -- through the Health Benefit Exchange, the online insurance marketplace we named Kynect: Kentucky's Healthcare Connection.
Kentucky is the only Southern state both expanding Medicaid and operating a state-based exchange, and we remain on target to meet the Oct. 1 deadline to open Kynect with the support of a call center that is providing some 100 jobs. Having been the first state-based exchange to complete the readiness review with the United States Department of Health and Human Services, we hope to become the first one to be certified.
Frankly, we can't implement the Affordable Care Act fast enough.
As for naysayers, I'm offended by their partisan gamesmanship, as they continue to pour time, money and energy into overturning or defunding the Affordable Care Act. It's shameful that these critics haven't invested that same level of energy into trying to improve the health of our citizens.
They insist that the Affordable Care Act will never work -- when in fact a similar approach put into effect in Massachusetts by Mitt Romney, then the governor, is working.
So, to those more worried about political power than Kentucky's families, I say, ''Get over it.''
The Affordable Care Act was approved by Congress and sanctioned by the Supreme Court. It is the law of the land.
Get over it ... and get out of the way so I can help my people. Here in Kentucky, we cannot afford to waste another day or another life.
URL: http://www.nytimes.com/2013/09/27/opinion/my-state-needs-obamacare-now.html
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The New York Times
March 14, 2017 Tuesday
Late Edition - Final
Trump's Often Misleading Critiques of the Affordable Care Act
BYLINE: By LINDA QIU
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 975 words
WASHINGTON -- President Trump blamed the news media on Monday morning for ''making Obamacare look so good'' as he spoke at a listening session with nine people he characterized as ''victims'' of the health care law.
Mr. Trump repeated his declaration that ''Obamacare is a disaster'' -- a sentiment echoed more specifically by White House and cabinet officials in the past few days.
While it is undeniable that the law has not been universally beneficial, many of the criticisms from Mr. Trump and his team are cherry-picked or misleading.
Mr. Trump pointed to high premium increases.
''You represent the millions of American who have seen their Obamacare premiums increase by double digits and even triple digits.''
This needs context. In 2017, premiums for the benchmark plan increased by 22 percent on average across the states that use the federal marketplace or have their own exchanges, according to the Department of Health and Human Services. Some places had higher increases (116 percent in Arizona, the only state with a triple-digit increase) and some lower (9 percent in Wyoming).
That's much higher than the 7 percent increase in 2016 and 3 percent increase in 2015, but looking at premium increases alone does not fully capture what people are paying.
About 84 percent of enrollees qualify for tax credits that help blunt the costs in 2017, meaning the government picks up the tab for any increase. Factoring in this financial assistance, a 40-year-old nonsmoker making $30,000 would see no change, or even a slight reduction, for the benchmark plan in all but two states, the Kaiser Family Foundation estimated.
Mr. Trump criticized the law for having little impact on the number of insured.
''First of all, it covers very few people.''
False. About 20 million have gained insurance under the act. The uninsured rate fell to 10.9 percent at the end of last year, according to Gallup, compared with 17.1 percent at the end of 2013. Analysis from the Commonwealth Fund concluded that the Affordable Care Act was responsible for a majority of the decline.
Mr. Trump suggested millions are unsatisfied with the Affordable Care Act or lost health care because of it.
''Millions of people had great health care that they loved. Now when you start deducting those millions of people from the so-called people who are happy, you have a very small number of people that are happy.''
This is misleading. Researchers at the Urban Institute estimated that roughly 2.6 million people reported in 2013 that their plans were being canceled because of noncompliance with the A.C.A. But half of these people were eligible for Medicaid or subsidized insurance plans. A 2014 study from the RAND corporation, a nonprofit think tank, concluded that fewer than one million people, not ''millions,'' ended up with no insurance at all.
Most polls also contradict Mr. Trump's claim that there is a ''very small number of people that are happy.'' A majority of enrollees reported satisfaction with the health care law in three national surveys, though some expressed concern with lack of choice and affordability, according to a September 2016 Government Accountability Office review. (The outlier is Black Book Market Research, a public opinion research company based in Florida, which found just 22 percent of enrollees were satisfied.)
Tom Price, the secretary of health and human services, suggested the Affordable Care Act has forced workers to take on multiple jobs.
''You hear people's lives that have been affected in remarkably adverse ways that sometimes you don't think about as it relates to health care -- whether it's businesses that haven't been able to survive, or individuals who need to take three, four, five jobs.''
This is misleading. The Affordable Care Act mandated that businesses with more than 50 employees are required to offer health insurance to employees who work 30 hours or more per week, or pay a penalty. Though there are certainly some anecdotes of employers reducing hours to get around the mandate, studies have been unable to find much evidence of a widespread shift to part-time employment.
Mr. Price argued that Medicaid, not the Affordable Care Act, is the leading driver of more coverage.
''Well, in fact the number of individuals who actually got coverage through the exchange who didn't have coverage before, or who weren't eligible for Medicaid before is relatively small. So we've turned things upside down completely for three or four or five million individuals.''
This is misleading. Out of the 20 million people who have gained insurance under the law, about 14.5 million received coverage through Medicaid, 3.3 million of whom were previously eligible.
A majority of these Medicaid enrollments, 11.2 million, occurred because of the Affordable Care Act's expansion of the health care program. The health care law raised the eligibility cutoff to adults under 65 who made less than 138 percent of the poverty line.
Sean Spicer, the White House press secretary, claimed the Affordable Care Act has caused increases in private employer-based insurance as well.
''We went in to solve a problem that a small fraction of Americans had and we upended the entire system forcing premiums to go up and choice to go down for everybody.''
This is misleading. Health costs for employer-sponsored plans have risen in the years since the law was implemented. Independent estimates for the rate of increase hover in the 3 percent to 4 percent range.
But this trend was occurring in the years before the Affordable Care Act as well. The Kaiser Family Foundation estimates that premiums increased by 20 percent from 2011 to 2016, compared to 31 percent from 2006 to 2011 and 63 percent from 2001 to 2006.
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URL: http://www.nytimes.com/2017/03/13/us/politics/fact-check-trump-obamacare-health-care.html
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(Economix)
May 22, 2013 Wednesday
Massachusetts Employees Will Keep Their Health Plans
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 959 words
HIGHLIGHT: Because the state’s employees are relatively highly paid, the impact of Massachusetts’ health care reform is likely to be different than that of the Affordable Care Act, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Massachusetts and a few neighboring states are likely to experience the Affordable Care Act a lot differently than the rest of America.
Massachusetts is often held up as a window into America's health insurance future, because it embarked on what came to be called the Romneycare reform six years ago. Like the Affordable Care Act provisions going into effect nationwide next year, Romneycare aimed to increase the fraction of the population with health insurance by imposing mandates on employers and employees and by subsidizing health insurance plans for middle-class families without employer plans.
Because the subsidized plans are available for only low- and middle-income families whose employers do not offer affordable health benefits, some analysts fear employers around the nation will drop their health benefits as the Affordable Care Act goes into full effect, resulting in millions of people losing the opportunity to get health insurance through an employer.
But some people say they believe this fear is likely to be unfounded, because the propensity of Massachusetts employees to receive employer-sponsored health insurance was hardly different after Romneycare went into effect than it was in the years before.
The details and dollar amounts in the Massachusetts health care law differ from the national Affordable Care Act, and for that reason alone I hesitate to infer too much from the Massachusetts experience. Even if the two laws were essentially the same, the effects in Massachusetts could be different than the national effects because Massachusetts has a different population and business environment than the rest of the nation.
Last week I explained how specific types of employers could be expected to drop their health benefits during the next couple of years: those employers that currently offer benefits but nonetheless pay much of their payroll to people living in households below 300 percent of the federal poverty line, who are eligible for the most generous federal subsidies as soon as their employer ceases to offer benefits.
Massachusetts has an extraordinary fraction (almost two-thirds) of its population above 300 percent of the federal poverty line, and as a result practically all Massachusetts employers will prefer to retain their health benefits over the next few years, even though a significant fraction of employers elsewhere will not.
One way to quantify the difference between Massachusetts employers and employers elsewhere is in the percentage of payroll going to employees from families below 300 percent of the poverty line. At a national level, the percentage varies from 4 percent in Internet publishing to about 50 percent in restaurants and private household employers. The national average is 20 percent, compared with 13 percent in Massachusetts.
Employers have a variety of factors to consider in their benefit offering decisions, but I have made some estimates that focus on the payroll-composition statistics noted above. By my estimates, employers with percentages of 26 to 35 percent of employees above 300 percent of the poverty level have a sufficiently high percentage that they are likely to have been offering health insurance benefits before the Affordable Care Act. Yet they have a low enough percentage that their employees gain on average if the employer health benefit is dropped and employees take the subsidies available through the Affordable Care Act's health insurance exchanges.
About 10 percent of employees with health insurance live in a state and work in an industry with compensation percentages in the range where profits are to be gained by dropping employer health insurance. But none of them live in Massachusetts, and some states that border Massachusetts, including New Hampshire and Connecticut, are in a similar situation.
A number of states and industries - especially the industries I emphasized last week - have more than 35 percent of their payroll paid to people in families under 300 percent of the poverty line and are unlikely to be offering employee health benefits.
But those employers in Massachusetts who have 35 percent of their payroll paid to people in families under 300 percent of the poverty line are more likely to offer some kind of health benefit, in part because of Romneycare's incentives to create "cafeteria plans" in which employees authorize pretax salary to be withheld from their paychecks for the payment of health insurance premiums.
Under the federal law, the Massachusetts cafeteria plans will lose some of their advantages to employers in terms of avoiding penalties for failure to offer health benefits.
Based on the combination of these two factors - that no Massachusetts industries have 26 percent to 35 percent of their employees under 300 percent of the poverty line, and that Massachusetts employers will lose the advantages of their cafeteria plans - I calculate that employers offering health insurance in Massachusetts are one-third as likely to drop their employee health plans over the next couple of years as are employers in the rest of the nation.
That's because the percentage of the United States work force at risk of losing its employer insurance (because of the tendencies of their industry and states to have low- and middle income employees) is three times the percentage of the Massachusetts work force in the same situation.
Health Coverage Worthy of a Senator
Health Reform, the Reward to Work and Massachusetts
Patterns of Changes in Health Insurance
Hammurabi's Code and U.S. Health Care
Small Companies and the Affordable Care Act
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The New York Times
January 14, 2017 Saturday
Late Edition - Final
The Republicans vs. Obamacare
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 18
LENGTH: 603 words
To the Editor:
Re ''The Fight for Health Care Has Begun'' (column, Jan. 10): David Leonhardt is correct about the Republicans' wish to crush the Affordable Care Act. But their likely strategy is one of neglect. They will shout ''repeal, repeal'' and cause such confusion that some insurance companies will drop out, premiums will rise and patients will be so uncertain about their options that they will not sign up.
The G.O.P. will then say ''see, it's a failure'' and offer unworkable travesties like high-risk pools. The Republicans can then move on with their real agenda to privatize Medicare and provide starvation block grants to unravel Medicaid.
JAMES WEBSTER
Santa Fe, N.M.
The writer is professor emeritus of medicine at the Feinberg School of Medicine, Northwestern University.
To the Editor:
Re ''Trump Orders Swift Remake of Health Act'' (front page, Jan. 11):
Poor Donald! He apparently believed the Republican rhetoric that Obamacare failed. In publicly exhorting his party's congressional majority to repeal the Affordable Care Act and come up with a replacement at or near the same time, he doesn't realize that his party doesn't have and never did have a replacement, despite years of its repeated votes to repeal the law.
And the only effective replacement that won't explode the deficit would either be essentially the same as the Affordable Care Act or a single-payer insurance system. Sad!
SHARON MORRISON
Whitefish, Mont.
To the Editor:
The reason Republicans can't come up with a replacement for the Affordable Care Act is that it was their plan in the first place. It was devised at the conservative Heritage Foundation, enacted in Massachusetts by Gov. Mitt Romney, a Republican, and is essentially a market-based system to require people to buy private health insurance.
Privatization is the Republicans' solution to every problem (see also: education, infrastructure), and now that President Obama has tried it, they have nowhere else to turn. It is hard to understand how this simple truth has escaped attention in the public discourse.
ROBERT NEUGEBOREN
Cambridge, Mass.
To the Editor:
Re ''Health Lobby Quiet as Law Faces Repeal'' (front page, Jan. 10):
Why are the health care lobbyists and executives ''stunned'' at the speed with which the Republicans are trying to repeal the Affordable Care Act in Congress? Election Day should have been their wake-up call to expect and prepare for yet another bill to repeal Obamacare.
You report that the president of the Greater New York Hospital Association said health care executives ''don't want to get on the wrong side of the new administration or the Republican majority in Congress.'' These health care executives seem to cower rather than stand up for the millions who could lose health care coverage and watch as the health system is dismantled.
At this pivotal time, we need those in power to stand up for what is right and honorable especially for those in need.
JACQUELINE JONES
Portland, Ore.
To the Editor:
I doubt that companies ''were afraid to speak out'' merely because ''they feared that Mr. Trump would attack them on Twitter.'' Unlike Donald Trump, companies don't have fragile egos that can be damaged by a tweet. They might lose some customers, but probably not a decisive number.
More likely, the companies are afraid that Mr. Trump will mark them for revenge, and use presidential powers to exact it. They may also fear that business partners will shun a company at odds with Mr. Trump.
Such thinking is common in dictatorships. Is that where we're headed?
ILYA SHLYAKHTER
Cambridge, Mass.
URL: http://www.nytimes.com/2017/01/13/opinion/the-republicans-vs-obamacare.html
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The New York Times
March 25, 2017 Saturday
Late Edition - Final
The Republicans' Health Care Defeat
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 20
LENGTH: 577 words
To the Editor:
The Republican-led House of Representatives just presented President Trump and Speaker Paul Ryan with a stunning political defeat by failing to support the bill to repeal the Affordable Care Act (nytimes.com, March 24).
Is this what Mr. Trump calls the ''Art of the Deal''? Perhaps his vaunted negotiating skills do not translate well into the political arena. In any event it was a totally self-inflicted wound. Why?
First, it was a mistake to start his legislative agenda with health care ''reform.'' He should have started with tax and regulatory reform, much less contentious and much easier to pass.
Second, it was self-inflicted because the Republican Party leaders (at least Mr. Ryan) took their own campaign rhetoric too literally. They had been beating the drum for repeal and replace Obamacare for so long they actually believed it was what the people wanted (the majority do not).
They could have chosen to just repeal it now, with an effective repeal date in one year. Then they could have tried to work on a bipartisan bill with more real popular support and passed it next year.
Mr. Trump, right about now I'm guessing you really wish you had the absolute power of Vladimir Putin to effect change; you do not. There are real limits to your power, as we have just seen amply demonstrated.
KEN DEROW, SWARTHMORE, PA.
To the Editor:
Former President Barack Obama enjoys vindication as a colossal embarrassment has been sustained by President Trump and House Republicans, both forced to share blame for the collapse of their much-heralded American Health Care Act.
Mr. Trump exerted brute force in an effort to secure votes for the plan, and he got nowhere. Republican House members recognized that their primary allegiance is not to their president, but to the constituents before whom they will appear on the ballot next year. Conservatives found the bill to be too generous, while moderates concluded that it was cruel.
Changes should be made to the Affordable Care Act to make it sustainable. If the Republicans want to make those changes, they will have to eat crow, and work with Democrats who will insist on maintaining the framework of the Obama legislation.
Could this stunning defeat cause President Trump to finally demonstrate some humility?
OREN M. SPIEGLERUPPER ST. CLAIR, PA.
To the Editor:
After seven years of unrelenting contempt for President Obama and the Affordable Care Act, and with seven years to come up with an alternative, the Republicans, now that they have control of Congress and the White House, just showcased their incompetence.
The only surprise would be if, after this fiasco, they were willing to work with Democrats to actually improve the Affordable Care Act. I'm not holding my breath.
CHARLES MERRILL, NEW YORK
To the Editor:
Republicans have never liked the idea of a national health care system. President Obama's triumph in passing the Affordable Care Act infuriated them into an obsession to make it fail by any means necessary, lying about its successes and convincing their base that it was a terrible system.
Now the Republicans are facing a crisis of their own making, when a bipartisan effort could have made the Affordable Care Act work for everyone at reasonable costs.
Of course, it would be so much easier (and less expensive) to expand Medicare to cover all Americans -- but that would make Republicans' heads explode, so it's off the table.
CAROL ROBINSON, NEW YORK
URL: http://www.nytimes.com/2017/03/24/opinion/the-republicans-health-care-defeat.html
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January 5, 2017 Thursday 00:00 EST
The Health Care Plan Trump Voters Really Want;
Op-Ed Contributor
BYLINE: DREW ALTMAN
SECTION: OPINION
LENGTH: 974 words
HIGHLIGHT: The push to replace Obamacare does not reflect the desires of working-class voters. They want practical solutions to their health care problems.
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump - people who are enrolled in the very health care marketplaces created by the law - one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.
Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.
The Kaiser Foundation organized six focus groups in the Rust Belt areas - three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn't really know what he would do, and were worried about what would come next.
They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance - for which they were eligible for subsidies - saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.
Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.
When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called "chaos" if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, "a smart businessman like Trump would let that happen." Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.
There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as "un-American."
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.
Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.
In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.
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Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation.
DRAWING (DRAWING BY ELLEN SURREY)
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December 31, 2016 Saturday 00:00 EST
Job No. 1 for a New Congress? Undoing Obama's Health Law
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 979 words
HIGHLIGHT: Republicans plan to waste no time repealing the Affordable Care Act, a signature part of President Obama's legacy.
WASHINGTON - Congress often waits for a new president to take office before it gets down to business. This year, Republicans will drop that custom in their dash to scrap the Affordable Care Act.
Within hours of the new Congress convening on Tuesday, the House plans to adopt a package of rules to clear the way for repealing the health care law and replacing it with as-yet-unspecified measures meant to help people obtain insurance coverage.
Then, in the week of Jan. 9, according to a likely timetable sketched out by Representative Greg Walden, Republican of Oregon, the House will vote on a budget blueprint, which is expected to call for the repeal of the Affordable Care Act.
Later, in the week starting Jan. 30, said Mr. Walden, incoming chairman of the House Energy and Commerce Committee, the panel will act on legislation to carry out what is in the blueprint. That bill would be the vehicle for repealing major provisions of the health care law, including the expansion of Medicaid.
Republicans in both houses of Congress have said that repealing the health law is a top priority for the first months of 2017. "The Obamacare repeal resolution will be the first item up," said the Senate majority leader, Mitch McConnell, Republican of Kentucky.
President-elect Donald J. Trump has called the law an "absolute disaster," and has said he is eager to sign a repeal bill like one vetoed by President Obama in early 2016.
Representative Nancy Pelosi of California, the House Democratic leader, said the rules devised by House Republicans were "their opening salvo" against a law that she said had been "successful in meeting its goals of reducing cost, increasing access and improving quality of care."
In a last-ditch bid to save his signature legislative achievement, which has provided coverage to some 20 million Americans, Mr. Obama plans to visit a meeting of House and Senate Democrats on Wednesday to rally support for the law.
The Affordable Care Act, approved in 2010 without any Republican votes, provides tax credits to help people buy private insurance. It also allowed states to expand Medicaid eligibility, with the federal government paying most of the cost for new beneficiaries.
The law also saves hundreds of billions of dollars by reducing the growth of Medicare payments to hospitals, nursing homes, health maintenance organizations and other health care providers. Repealing the law would eliminate those savings and thus increase federal spending, the Congressional Budget Office says.
The proposed rules written by House Republicans allow lawmakers to raise a point of order against legislation that causes an increase in certain types of federal spending. But the rules give special protection to bills repealing or "reforming" the Affordable Care Act, even if such bills cause a temporary increase in spending.
Republicans worry that the Congressional Budget Office could count their plan for replacing the law as new spending, making it subject to challenge on the House floor. The exception being written into House rules would help them avoid that possibility.
Ms. Pelosi pointed to this provision as evidence that the health care law, as written, saves money. In their version of the rules, she said, "Republicans are admitting that repealing the Affordable Care Act will increase costs."
The Congressional Budget Office said in 2015 that "repealing the A.C.A. would raise federal deficits by $137 billion over the 2016-2025 period" - not only because the government would spend more on Medicare, for older Americans, but also because it would collect less in taxes from high-income households.
The 2010 law, the budget office noted, increased the payroll tax rate for many high-income taxpayers and imposed a surtax on their net investment income. The law also imposed annual fees on health insurers and manufacturers of brand-name drugs and medical devices.
Republicans may want to hold on to some of the tax revenue and Medicare savings, to help offset the cost of their plan to replace the Affordable Care Act. They have been trying to devise that replacement, but do not have a consensus and may hold hearings to examine the options.
If Congress votes to repeal the health care law early in 2017, Republican leaders say, they may delay the effective date for several years, to avoid disrupting coverage for people who have recently gained it.
The Republican rules package would also allow the House to continue its legal challenge to spending on insurance subsidies that reduce out-of-pocket costs for more than six million Americans.
In addition, the rules would require House committee chairmen to propose ways of imposing more fiscal discipline on federal entitlement programs. In the jargon of the federal budget, the goal is to switch some programs from "mandatory funding" to "discretionary appropriations," over which Congress has greater control.
This rule mirrors ideas advanced by Representative Tom Price, Republican of Georgia and chairman of the House Budget Committee, whom Mr. Trump has selected to be his secretary of health and human services.
"Two-thirds of current expenditures are dedicated to a relatively small number of automatic spending programs like Medicare, Medicaid and Social Security, which are not subject to annual appropriations and therefore operate largely outside the control of Congress," Mr. Price said in a recent speech.
PHOTO: Mitch McConnell, the Senate majority leader, has said that repealing the Affordable Care Act was the new Congress's top priority. (PHOTOGRAPH BY MARK WILSON/GETTY IMAGES) (A16)
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Let's Say Obamacare Is Repealed. What Then?
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July 10, 2013 Wednesday
Taxing Employers and Employees
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 774 words
HIGHLIGHT: The Affordable Care Act will disrupt and distort labor markets in a variety of ways, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The delay of the Affordable Care Act's employer mandate is a favorable development for the labor market, but the employer mandate is only the tip of the iceberg in terms of the labor-market distortions that the law has scheduled to come on line next year.
The Affordable Care Act's employer mandate will eventually levy a penalty on large employers that do not offer affordable health insurance to their full-time employees. The penalty is based on the number of full-time employees and adds about $3,000 to the annual cost of employing each person.
Employers have been complaining about the penalty, saying it will reduce the number of people they hire and cause them to reduce employee hours. Even economists and commentators supporting the law acknowledge that per-employee penalties reduce hiring by raising the cost of employment.
Economists have traditionally recognized that it hardly matters whether a tax is levied on employers or on employees, especially in the long run. In the employee-tax case, the employee pays the tax directly. In the employer-tax case, the employee pays the tax indirectly through reduced pay, because employer penalties reduce the willingness of employers to compete for people (Jonathan Gruber of the Massachusetts Institute of Technology has provided some good evidence in support of this widely accepted economic proposition).
Among other things, employment, employer costs and employee take-home pay would be essentially the same if the government levied a $3,000 fine on workers for having a full-time job with a large employer that does not offer health benefits, rather than levying the fine on employers on the basis of their full-time personnel, as the Affordable Care Act does.
But the political optics of the two policies are dramatically different. Large businesses can supposedly afford $3,000 per employee, while many employees could not afford another $3,000 bite out of their paychecks. Like it or not, economics' equivalence results tells us employees will have to afford what amounts to a tax on them beginning in 2015, pursuant to the Treasury Department's decision to begin collecting the employer penalty in that year.
For the purposes of understanding the state of the labor market, it doesn't really matter whether individuals would be paying a tax for having a full-time job or receiving a subsidy for not having a full-time job. Either policy would reduce the gap between the income of full-time employees and everybody else. The ultimate result will be less full-time employment, in an amount commensurate with the size of the tax or subsidy.
The Affordable Care Act offers subsidies for people without work or in part-time positions that far exceed $3,000 per employee per year, which makes the employer mandate only a small piece of the law's employment effects.
The law's other new work-disincentive provisions, still on schedule for next year, include (i) a sliding income scale that sets premiums for people who buy health insurance on the new marketplaces, (ii) a plan for premium assistance that essentially resurrects the Recovery Act's subsidy for what are known as Cobra benefits, allowing employees who have left a job to continue to participate, for a limited time, in their former employer's health plan, in a more comprehensive form and (iii) hardship relief from the individual mandate.
As an example of these provisions, I explained last week how, even without the employer penalties, the premium assistance plan sharply penalizes full-time employment in favor of part-time employment. In combination, the provisions going into effect next year are two or three times larger than the employer mandate by itself, depending on the type of worker and the industry of employment.
Proponents of the Affordable Care Act, including a number of economists, have yet to acknowledge that so many provisions of the act have, from a labor economics perspective, so much in common with the employer mandate. But labor-market distortions are a common feature of several significant parts of the act and are an important part of what has happened in our labor market.
Whatever labor market benefits accrue from delaying the employer mandate could be had many times over by delaying the entire Affordable Care Act.
The New Economics of Part-Time Employment
What Job-Sharing Brings
Hidden Costs of the Minimum Wage
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
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December 6, 2016 Tuesday 00:00 EST
Addiction and the Health Law;
Letter
SECTION: OPINION
LENGTH: 228 words
HIGHLIGHT: The National Center on Addiction and Substance Abuse writes that repealing the Affordable Care Act will undermine efforts to reduce addiction.
To the Editor:
Re "The G.O.P. and Health Care Chaos" (editorial, "What's at Stake" series, Nov. 28): Repealing the Affordable Care Act will significantly undermine efforts to reduce addiction.
First, the 22 million people at risk of losing their health insurance have higher rates of substance use disorders than the general population. Second, the law requires health plans to offer addiction benefits and prohibits plans from imposing more restrictive limits or higher out-of-pocket costs on those benefits as compared with similar medical/surgical benefits.
These provisions in the health law are the strongest protections available for health care consumers seeking addiction treatment paid for by their insurance.
Our country is divided on many issues, including the health law, but there is widespread agreement that addiction is a major problem.
The Affordable Care Act is not a perfect law, but it offers some of the best tools available for increasing addiction treatment access. Whatever proposal the new administration puts forward should include similar or better provisions to ensure that people with addiction can get treatment.
We cannot stop the opioid epidemic if people do not have health insurance that covers treatment.
LINDSEY VUOLO
New York
The writer is associate director of health law and policy at the National Center on Addiction and Substance Abuse.
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January 5, 2017 Thursday 00:00 EST
The Health Care Law, Imperiled;
Letters
SECTION: OPINION
LENGTH: 566 words
HIGHLIGHT: Readers share views about the Republican dismantling of Obamacare.
To the Editor:
Re "Senate G.O.P. Opens Fight Over Obama Health Law" (front page, Jan. 5):
Given that the Republicans in Congress have offered nothing more than the lies of their own manufactured outrage to justify the haste and glee with which they are about to dismantle Obamacare, their actions can only be seen as a final act of political retribution against a president they never accepted or planned to work with in good faith.
The fact that more than 22 million people may lose access to health coverage as a result of this act of political callousness only cements the perception that the Republican Party is a morally and ethically bankrupt party that cannot be trusted to govern or participate responsibly in our democracy.
MICHAEL SCOTT
San Francisco
To the Editor:
Re "Republicans' Four-Step Plan for Dismantling the Care Act" (front page, Jan. 5):
As a physician, I have seen firsthand the transformation of our health care system under the Affordable Care Act. The law is imperfect, as all laws are, but it has provided the necessary framework to control costs (and would be working even better if the incremental changes it needs had not been blocked by a hostile Congress for six years).
In its most important mission - bringing health insurance to all Americans, including those previously uninsurable because of pre-existing conditions - the law is a resounding success. I can state without equivocation that I have cared for patients who owe their lives to the Affordable Care Act, and that full repeal of this law will kill people.
NIKHIL SINGH
New Haven
The writer is a nephrology fellow at the Yale School of Medicine.
To the Editor:
President Obama's Affordable Care Act is not the culprit in the disaster that is the distribution of health care in America.
The most powerful Congressional lobby today is not the National Rifle Association or the military-industrial complex. It is the vast health-care-industrial complex, stretching across insurance, pharmaceutical and medical supply companies and down to hospitals and the American Medical Association, each feeling entitled to a share of the patient's wallet.
This is the capitalist ethic at its worst.
Republicans and libertarians cavalierly rail against entitlements and "people living off the public's dime" but remain silent on those profiting from people's misfortune and illness.
It will be interesting to see how Donald Trump's billionaire cabinet, secure and insured in its entitled wealth, will approach reforming Obamacare.
ROBERT PORATH
Boulder, Colo.
To the Editor:
Re "Safety-Net Hospitals Fear Cuts as Health Law's Repeal Looms" (front page, Dec. 28):
Simply put, hospitals that disproportionately serve Medicare and Medicaid patients (and thus very few commercially insured patients) are financially unsustainable because of severe underpayments.
In New York State alone, 27 hospitals are on a "watch list" for financial vulnerability, and many more are in similar fiscal distress. Repealing the Affordable Care Act without an immediate and adequate replacement will make things dramatically worse.
The health law is far from perfect, and long-term improvements are certainly necessary. But Washington would be wise to avoid decisions that will severely - and perhaps irreparably - harm America's safety-net hospitals and the vulnerable communities they serve.
KENNETH E. RASKE
President, Greater New York
Hospital Association
New York
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February 13, 2014 Thursday
Massachusetts Is Given Extension
SECTION: US
LENGTH: 576 words
HIGHLIGHT: The state, which had its own health insurance exchange before the Affordable Care Act, has been given another three months to manage a balky transition.
BOSTON - Massachusetts officials said Thursday that they have an additional three months to bring the state's health care system in line with the national Affordable Care Act.
The waiver, which was granted by federal officials on Wednesday, will allow the state to keep more than 100,000 individuals on state-run health insurance plans that do not comply with the requirements of the new law until June 30.
"We are determined to get this project back on track and get people out of this temporary coverage plan and transition to the program that they belong in," said Sarah Iselin, a health insurance executive who was appointed last week by Gov. Deval Patrick to oversee repairs to the state's troubled efforts to update its online health insurance exchange so it complies with the federal law.
Massachusetts created its own online marketplace for health insurance when it passed a health care overhaul in 2006. That website functioned as intended until it was changed last fall to bring it up to date with the requirements of the Affordable Care Act. The site had problems determining whether many applicants were eligibile for the federal subsidies, and left tens of thousands of applications to be processed by hand.
Unable to immediately enroll applicants in new, private plans under the Affordable Care Act, state officials extended existing state coverage for about 110,000 individuals, and granted temporary state coverage to about 30,000 new applicants. Those individuals were supposed to move onto new plans by March. 31; the federal waiver gives officials another three months to do that.
"This is not a position we wanted to be in," said Ms. Iselin, who said there was a backlog of an additional 50,000 applications that had yet to be processed.
A health care technology firm, Optum, has been hired by the state to help process those applications and improve the functionality of the exchange website.
Last week, state officials released a report by an outside technology firm, Mitre Corporation, that criticized both the state and its principal contractor, CGI, for the failure of Massachusetts' new health exchange website. The report said that state organizations leading the website's overhaul lacked a "unified vision" for the project and that CGI lacked adequate expertise, managed the project poorly, lost data and failed to do enough testing before the launch of the new site.
The problems have been embarrassing to proponents of the federal health care overhaul who have pointed to Massachusetts as a successful implementation of a health exchange and an individual mandate.
Ms. Iselin said that part of the challenge here was that Massachusetts, which had the only state insurance marketplace before the Affordable Care Act was passed, was not simply extending coverage to new individuals but moving people from its old system to a new one.
"In some ways, it's made this part of implementing the A.C.A. more complex for us than other places that didn't have the same long history of these incremental expansions," she said.
The state originally asked for a six-month extension. Ms Iselin said it was "too soon too tell" whether they would need more than the three months they got.
Massachusetts Appoints Official and Hires Firm to Fix Exchange Problems
Maine Hires Firm to Study Medicaid System, to Democrats' Ire
White House to Tweak Tax-Penalty Deadline
New Ad Campaign Criticizes Senators for Support of Health Law
Broad Skepticism on Health Care Law
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February 10, 2015 Tuesday
No 'Manly Firmness' in Denying Health Care, McCaskill Says
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 201 words
HIGHLIGHT: Is repealing the Affordable Care Act an issue of manhood?
Is repealing the Affordable Care Act an issue of manhood?
A state representative in Missouri suggested as much in a resolution asking members of the state's congressional delegation to undo the law.
The bill, introduced by State Representative Mike Moon, a Republican, insists that "each member of the Missouri congressional delegation endeavor with 'manly firmness' and resolve to totally and completely repeal the Affordable Care Act, settling for no less than a full repeal."
The macho language raised the eyebrows of Senator Claire McCaskill, a Missouri Democrat who has been a defender of the law.
"I don't think you prove your manhood by kicking folks off their health coverage and once again letting insurance companies discriminate against women and sick people," Ms. McCaskill said in a statement.
Mr. Moon told The Columbia Daily Tribune that he did not mean to offend women with the language in his bill. The phrase, he said, was a reference to a line about fighting for freedom that was written in the Declaration of Independence.
"It is just like going to war," Mr. Moon told the paper. "You want a soldier to fight like a man. If a woman is in the trenches, you want them to fight like a man, too."
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December 29, 2014 Monday
Obama Says Health Law Is Helping White Americans, Despite Perceptions
BYLINE: MICHAEL S. SCHMIDT
SECTION: US; politics
LENGTH: 375 words
HIGHLIGHT: In an interview scheduled to air Monday on NPR, President Obama said that despite the perception the Affordable Care Act is for blacks and Latinos, it is helping many whites.
HONOLULU - President Obama said that despite the perception that the Affordable Care Act is for blacks and Latinos, it is helping many whites.
"The truth of the matter is that a state like Kentucky that doesn't have a massive black or Hispanic population has been one of the strongest states," Mr. Obama said in a wide-ranging interview scheduled to be broadcast on NPR on Monday.
The president said that Kentucky - represented by the incoming majority leader, Senator Mitch McConnell - was "one of the best states in using the Affordable Care Act to insure huge number of working-class white voters."
But, he said, "they don't call it Obamacare; they call it something else."
Despite recent turmoil in Ferguson, Mo., and in New York City over relations between minorities and the police, the president said he believed that the United States was less racially divided than before he took office.
"I mean, the issue of police and communities of color being mistrustful of each other is hardly new: That dates back a long time," he said. "It's just something that hasn't been talked about - and for a variety of reasons."
Mr. Obama said it made sense that polls pointed to deteriorating race relations "because when it's in the news and you see something like Ferguson or the Garner case in New York, then it attracts attention."
"But I assure you, from the perspective of African-Americans or Latinos in poor communities who have been dealing with this all their lives, they wouldn't suggest somehow that it's worse now than it was 10, 15 or 20 years ago."
In regard to international relations, Mr. Obama said that his "strategic patience" had gotten lost in the 24-hour news cycle.
"You'll recall that three or four months ago, everybody in Washington was convinced that President Putin was a genius," he said.
He added: "I said at the time we don't want war with Russia, but we can apply steady pressure working with our European partners, being the backbone of an international coalition to oppose Russia's violation of another country's sovereignty, and that over time, this would be a strategic mistake by Russia."
"And today, you know, I'd - I'd sense that at least outside of Russia," he said, "maybe some people are thinking what Putin did wasn't so smart."
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March 7, 2017 Tuesday
Late Edition - Final
G.O.P. Health Bill Trades Mandate for Tax Credits
BYLINE: By ROBERT PEAR and THOMAS KAPLAN
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1498 words
WASHINGTON -- House Republicans unveiled on Monday their long-awaited plan to repeal and replace the Affordable Care Act, scrapping the mandate for most Americans to have health insurance in favor of a new system of tax credits to induce people to buy insurance on the open market.
The bill sets the stage for a bitter debate over the possible dismantling of the most significant health care law in a half-century. In its place would be a health law that would be far more oriented to the free market and would make far-reaching changes to a vast part of the American economy.
The House Republican bill would roll back the expansion of Medicaid that has provided coverage to more than 10 million people in 31 states, reducing federal payments for many new beneficiaries. It also would effectively scrap the unpopular requirement that people have insurance and eliminate tax penalties for those who go without. The requirement for larger employers to offer coverage to their full-time employees would also be eliminated.
People who let their insurance coverage lapse, however, would face a significant penalty. Insurers could increase their premiums by 30 percent, and in that sense, Republicans would replace a penalty for not having insurance with a new penalty for allowing insurance to lapse.
House Republican leaders said they would keep three popular provisions in the Affordable Care Act: the prohibition on denying coverage to people with pre-existing conditions, the ban on lifetime coverage caps and the rule allowing young people to remain on their parents' health plans until age 26.
Republicans hope to undo other major parts of President Barack Obama's signature domestic achievement, including income-based tax credits that help millions of Americans buy insurance, taxes on people with high incomes and the penalty for people who do not have health coverage.
Medicaid recipients' open-ended entitlement to health care would be replaced by a per-person allotment to the states. And people with pre-existing medical conditions would face new uncertainties in a more deregulated insurance market.
The bill would also cut off federal funds to Planned Parenthood clinics through Medicaid and other government programs for one year.
''Obamacare is a sinking ship, and the legislation introduced today will rescue people from the mistakes of the past,'' said Representative Kevin McCarthy of California, the majority leader.
Democrats denounced the effort as a cruel attempt to strip Americans of their health care.
''Republicans will force tens of millions of families to pay more for worse coverage -- and push millions of Americans off of health coverage entirely,'' said Representative Nancy Pelosi of California, the Democratic leader.
Two House committees -- Ways and Means and Energy and Commerce -- plan to take up the legislation on Wednesday. House Republicans hope the committees will approve the measure this week, clearing the way for the full House to act on it before a spring break scheduled to begin on April 7. The outlook in the Senate is less clear. Democrats want to preserve the Affordable Care Act, and a handful of Republican senators expressed serious concerns about the House plan as it was being developed.
Under the House Republican plan, the income-based tax credits provided under the Affordable Care Act would be replaced with credits that would rise with age as older people generally require more health care. In a late change, the plan reduces the tax credits for individuals with annual incomes over $75,000 and married couples with incomes over $150,000.
Republicans did not offer any estimate of how much their plan would cost, or how many people would gain or lose insurance. The two House committees plan to vote on the legislation without having estimates of its cost from the Congressional Budget Office, the official scorekeeper on Capitol Hill.
But they did get the support from President Trump that they badly need to win House passage.
''Obamacare has proven to be a disaster with fewer options, inferior care and skyrocketing costs that are crushing small business and families across America,'' said the White House press secretary, Sean Spicer. ''Today marks an important step toward restoring health care choices and affordability back to the American people.''
The release of the legislation is a step toward fulfilling a campaign pledge -- repeal and replace -- that has animated Republicans since the Affordable Care Act passed in 2010. But it is far from certain Republican lawmakers will be able to get on the same page and repeal the health measure.
On Monday, four Republican senators -- Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska -- signed a letter saying a House draft that they had reviewed did not adequately protect people in states like theirs that have expanded Medicaid under the Affordable Care Act.
Three conservative Republicans in the Senate -- Mike Lee of Utah, Rand Paul of Kentucky and Ted Cruz of Texas -- had already expressed reservations about the House's approach.
In the House, Republican leaders will have to contend with conservative members who have already been vocal about their misgivings about the legislation being drawn up. ''Obamacare 2.0,'' Representative Justin Amash, Republican of Michigan, posted on Twitter on Monday.
Representative Mark Meadows, Republican of North Carolina and the chairman of the conservative House Freedom Caucus, also offered a warning on Monday, joining with Mr. Paul to urge that Republican leaders pursue a ''clean repeal'' of the health care law.
''Conservatives don't want new taxes, new entitlements and an 'ObamaCare Lite' bill,'' they wrote on the website of Fox News. ''If leadership insists on replacing ObamaCare with ObamaCare-lite, no repeal will pass.''
The move to strip Planned Parenthood of funding and the plan's provisions to reverse tax increases on the high-income taxpayers will also expose Republicans in more moderate districts to Democratic attacks.
The bill would provide each state with a fixed allotment of federal money for each person on Medicaid, the federal-state program for more than 70 million low-income people. The federal government would pay different amounts for different categories of beneficiaries, including children, older Americans and people with disabilities.
The bill would also repeal subsidies that the government provides under the Affordable Care Act to help low-income people pay deductibles and other out-of-pocket costs for insurance purchased through the public marketplaces. Eliminating these subsidies would cause turmoil in insurance markets, insurers and consumer advocates say.
However, the House Republicans would provide states with $100 billion over nine years, which states could use to help people pay for health care and insurance.
The tax credits proposed by House Republicans would start at $2,000 a year for a person under 30 and would rise to a maximum of $4,000 for a person 60 or older. A family could receive up to $14,000 in credits.
Even with those credits, Democrats say, many people would find insurance unaffordable. But Republicans would allow insurers to sell a leaner, less expensive package of benefits and would allow people to use the tax credits for insurance policies covering only catastrophic costs.
While Republicans have argued over how to proceed, Mr. Trump has expressed only vague goals for how to repeal the Affordable Care Act and improve the nation's health care system. On Capitol Hill, lawmakers and their aides are waiting to see whether he uses his platform, Twitter account and all, to press reluctant Republicans to get behind the House plan.
The new version of the House Republican bill makes several changes to earlier drafts of the legislation.
It drops a proposal to require employees with high-cost employer-sponsored health insurance to pay income and payroll taxes on some of the value of that coverage. In addition, it would delay a provision of the Affordable Care Act that imposed an excise tax on high-cost insurance plans provided by employers to workers.
Congress had already delayed this ''Cadillac tax'' -- despised by employers and labor unions alike -- by two years, to 2020. The new legislation would suspend the tax from 2020 through 2024.
House Republicans would offer tax credits to help people buy insurance if they did not have coverage available from an employer or a government program. Under earlier versions of the bill, the tax credits increased with a person's age, but would not have been tied to income. Backbench Republicans said the government should not be providing financial assistance to people with high incomes.
Accordingly, under the new version of the bill, the tax credits would be reduced and eventually phased out.
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URL: http://www.nytimes.com/2017/03/06/us/politics/affordable-care-act-obamacare-health.html
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GRAPHIC: PHOTO: Speaker Paul D. Ryan last week in Washington. House Republicans have unveiled their plan to replace the Affordable Care Act. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A13)
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January 30, 2013 Wednesday
The Health-Care Law and Retirement Savings
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 568 words
HIGHLIGHT: The way in which pension contributions are treated for tax purposes could affect eligibility for premium assistance under the Affordable Care Act, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Because of its definition of affordability, beginning next year the Affordable Care Act may affect retirement savings.
Employer contributions to employee pension plans are exempt from payroll and personal income taxes at the time that they are made, because the employer contributions are not officially considered part of the employee's wages or salary (employer health insurance contributions are treated much the same way). The contributions are taxed when withdrawn (typically when the worker has retired), at a rate determined by the retiree's personal income tax situation.
Employees are sometimes advised to save for retirement in this way in part because the interest, dividends and capital gains accrue without repeated taxation. In addition, people sometimes expect their tax brackets to be lower when retired than they are when they are working.
These well-understood tax benefits of pension plans will change a year from now if the act is implemented as planned. Under the act, wages and salaries of people receiving health insurance in the law's new "insurance exchanges" will be subject to an additional implicit tax, because wages and salaries will determine how much a person has to pay for health insurance.
While much about the Affordable Care Act is still being digested by economists, they have long recognized that high marginal tax rates lead to fringe benefit creation. And the Congressional Budget Office has concluded that the act will raise marginal tax rates.
Were an employer to reduce wages and salaries (or fail to increase them) and compensate employees by introducing an employer-matching pension plan, the employee is likely to benefit by receiving additional government assistance with his health-insurance costs. The pension contributions will add to the worker's income during retirement, except that the income of elderly people does not determine health-insurance eligibility to the same degree, because the elderly participate in Medicare, most of which is not means-tested.
Take, for example, a person whose four-member household would earn $95,000 a year if his employer were not making contributions to a pension plan or did not offer one. He would be ineligible for any premium assistance under the Affordable Care Act because his family income would be considered to be about 400 percent of the poverty line.
If instead the employer made a $4,000 contribution to a pension plan and reduced the employee's salary so that household income was $91,000, the employee would save the personal income and payroll tax on the $4,000 and would become eligible for about $2,600 worth of health-insurance premium assistance under the act. (The employer would come out ahead here, too, by reducing its payroll tax obligations).
Even though the Affordable Care Act is known as a health-insurance law, in effect it could be paying for a large portion of employer contributions to pension plans. This has the potential of changing retirement savings and the relative living standards of older and working-age people.
When $250,000 Isn't Actually $250,000
With Higher Taxes Looming, Bonuses May Come Early
Tax Cuts, Tax Rates and Tax Shares
Romney's Tax Plan and Economic Growth
Republicans Champion 'Voluntary Taxes'
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February 13, 2016 Saturday
Late Edition - Final
Medicare Sign-Up Surge Confounds Expectations That Plans Would Falter
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 1422 words
WASHINGTON -- Five years into Medicare spending cuts that were supposed to devastate private Medicare options for older Americans, enrollment in private insurance plans through Medicare has shot up by more than 50 percent, confounding experts and partisans alike and providing possible lessons for the Affordable Care Act's insurance exchanges.
When Congress passed President Obama's signature health law nearly six years ago, it helped offset the cost by cutting payments to Medicare Advantage plans, offered by private insurers operating under contract with the government. Insurers and Republicans said the cuts -- about $150 billion over 10 years -- would ''gut'' the program, a major theme in the 2010 and 2012 elections. The Congressional Budget Office predicted that enrollment would fall about 30 percent.
In fact, more than 17 million people are now enrolled in such plans, up from under 11 million in 2010. Nearly one-third of Medicare beneficiaries have chosen private plans, offered by insurers like Humana and UnitedHealth Group, over the traditional fee-for-service Medicare program.
But some of the same insurers avidly seeking Medicare Advantage sign-ups have been apprehensive about enrolling people under 65 in public marketplaces created by the Affordable Care Act. It has taken herculean efforts by the Obama administration and by insurance counselors to sign up 12.7 million people -- far below the enrollment of 21 million in 2016 originally projected by the budget office.
The different trajectories of the two programs are explained by many factors, including money, market size and politics. Insurers know the Medicare population, know the rules of the program and have found ways to manage care that improve the health of Medicare patients and the financial health of the companies. They know much less about their new marketplace customers, many of whom were previously uninsured, and Congress, still bitterly divided over the health law, has done little to stabilize it.
''The size of the Medicare market is much larger,'' said Ana Gupte, a health care analyst at Leerink Partners in New York. ''The growth in the market is larger. Revenue per member is significantly higher, and the profitability is higher. So it's just better on all dimensions.''
For Medicare patients, the government pays insurers, on average, $10,000 a year per person -- a total of more than $170 billion -- and insurance executives say that well-run Medicare Advantage plans can often count on profit margins of 4 percent to 5 percent, even with the health law's spending reductions.
By contrast, securities analysts say, insurers typically receive an average of $3,000 to $5,000 a year in revenue for a person under 65 who signs up through the new marketplaces, and many insurers struggle to make a profit. Many insurers say they lost money on this program in 2014 and 2015, in part because they underestimated how much care their new customers would use.
Some insurers are so worried about losses on their exchange business that they have curtailed the active marketing of such plans. Kenneth J. Statz, an individual insurance specialist based near Cleveland, said major insurers were reducing or eliminating the commissions they paid to agents and brokers for enrolling people in marketplace plans, while continuing to pay for enrollment in Medicare plans.
''Even with all the cutbacks in the Affordable Care Act, there is still a decent opportunity for insurance companies to make a profit in the Medicare Advantage program,'' said Richard S. Foster, the former chief actuary of the Medicare program. ''The marketplace under the Affordable Care Act will calm down over time but may not ever be as stable and predictable as Medicare Advantage.''
The health care company Aetna said this month that its individual health insurance offerings under the Affordable Care Act ''remained unprofitable in 2015.'' Aetna's chief executive, Mark T. Bertolini, said the company had ''serious concerns about the sustainability of the public exchanges.''
But the company is bullish on Medicare. It announced last year that it would acquire Humana, another large insurer, pending antitrust review -- in part because Humana has more than three million people enrolled in Medicare Advantage plans.
Insurers say they have done everything possible to shield older Americans from the cuts in Medicare Advantage enacted in 2010. Private plans offer financial protection to Medicare beneficiaries, through a yearly limit on out-of-pocket costs, and often provide extra benefits not included in traditional Medicare.
''Seniors are increasingly choosing Medicare Advantage because they recognize the tremendous value of this program in their daily lives,'' said Marilyn B. Tavenner, the chief executive of America's Health Insurance Plans, a trade group, who used to run the federal Medicare program.
Many people under 65 have gained coverage because of the Affordable Care Act. But insurance markets in some states have been full of surprises for consumers and insurers alike, with volatile prices, nonprofit insurance cooperatives collapsing and enrollment in flux.
''In the Affordable Care Act marketplace, there has been an enormous amount of churning -- people dropping out, going into other plans -- so it's been very difficult for insurers to predict spending,'' said Prof. Dana Goldman, a health economist at the University of Southern California. ''By contrast, Medicare Advantage is a very predictable business.''
Medicare beneficiaries tend to stay in the same plan from year to year and generally give their plans high marks.
''These are vastly different programs with vastly different populations and vastly different rules,'' said Christine Arnold, a securities analyst at Cowen & Company who follows managed care companies.
Insurers and government officials are still trying to figure out the needs of people insured under the Affordable Care Act. In the course of a year, many people leave the rolls. Some fail to pay their share of premiums. Some qualify for Medicaid. Others get jobs that provide health insurance.
Then there are politics. It took many years for Medicare officials and Congress, working together, to refine the formula for paying private health plans for older Americans. From 2000 to 2003, insurers pulled out of many counties, disrupting coverage for hundreds of thousands of Medicare beneficiaries. Enrollment declined and then grew again after Congress increased payment rates. But bipartisan support for Medicare Advantage increased as insurers enlisted beneficiaries to tell Congress why they liked the program.
By contrast, continuing partisan strife over the health law means that insurers are exposed to political risks. Neither party is willing to reopen negotiations on the law's biggest issues, for fear of the consequences.
Congress did cut back special payments to insurers whose medical costs have exceeded their expectations, and those cuts contributed to the failure of insurance co-ops serving more than half a million people.
''Insurers want to play in this new market, but they are not completely sure what the rules of the game will be,'' said Michael E. Chernew, a professor of health care policy at Harvard Medical School.
UnitedHealth, one of the nation's largest insurers, said last month, ''We are off to our strongest growth start for Medicare Advantage in company history.'' Yet it lost $475 million on Affordable Care Act plans in 2015 and expected to lose a similar amount this year.
The company has said it will consider withdrawing from Affordable Care Act marketplaces in 2017.
Andrew M. Slavitt, the acting administrator of the federal Centers for Medicare and Medicaid Services, described such losses as ''growing pains'' suffered as insurers devised new business strategies and learned what products would appeal to consumers.
But he is also promising help. At a recent investor conference in San Francisco, Mr. Slavitt said he would take steps to prevent people from jumping in and out of the Affordable Care Act marketplace -- buying insurance when they needed costly care and then dropping it.
''Most insurers will stick with it,'' said Thomas A. Scully, who was administrator of the Centers for Medicare and Medicaid Services under President George W. Bush, ''because they cannot afford to abandon this market.''
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URL: http://www.nytimes.com/2016/02/13/us/politics/surge-in-medicare-advantage-sign-ups-confounds-expectations.html
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September 17, 2013 Tuesday
What's More Unpopular Than Health Care Reform?
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 289 words
HIGHLIGHT: Americans don’t want lawmakers to sabotage the Affordable Care Act.
A new Pew Research Center / USA Today poll indicates that Americans still haven't embraced the Affordable Care Act, President Obama's signature domestic policy measure. Fifty-three percent disapprove of the law, while 42 percent approve. That's a decline in the level of support since last July, when, in the wake of the Supreme Court decision upholding the law, 43 percent disapproved and 47 percent approved.
The big caveat here is that most Americans still don't understand what the law does. Only 25 percent say they understand the law's impact very well, 39 percent understand it somewhat, and a third have little or no understanding of how the law will affect them.
The other caveat is that, although a majority disapproves of the Affordable Care Act, few Americans support Republican attempts to mess it up.
According to Pew, about half of disapprovers, or 27 percent of the public overall, say elected officials who oppose the law "should do what they can to make the law work as well as possible," while 23 percent of the public holds the nihilistic view that they "should do what they can to make the law fail."
In other words, health care reform isn't popular, but sabotage is less popular. Sabotage isn't even particularly fashionable within the Republican Party. Only 43 percent of Republicans and Republican leaners want lawmakers to strive for failure.
As per usual, however, the outlook's different from the darker corners of the right wing. Sixty-four percent of Tea Party Republicans are in the forced-failure camp.
Ted Cruz Plays Two Truths and a Lie
Mitch McConnell Tries Leadership, Then Backs Away
Cheerleader for Healthcare Repeal Retires, Blaming Gridlock
What Republican Voters Want
The 'Just Say No' Approach to Governing
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June 10, 2015 Wednesday
Late Edition - Final
Before Supreme Court Weighs In, Obama Makes His Case for Health Law
BYLINE: By JULIE HIRSCHFELD DAVIS and MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 902 words
WASHINGTON -- President Obama on Tuesday condemned opponents of his signature health care law as ''cynical'' partisans seeking to deprive Americans of a benefit that has become an integral part of the country's social safety net, building a tough political case against Republicans as the Supreme Court weighs whether to strike down a key element of the Affordable Care Act.
''This is now part of the fabric of how we care for one another -- this is health care in America,'' the president said in a speech to the Catholic Health Association, an organization that championed the law and has written a brief asking the high court to uphold it. ''It seems so cynical to want to take health care away from millions of people.''
The court is expected to rule before the end of the month on whether to invalidate subsidies for millions of people who signed up for coverage through HealthCare.gov. If they do, millions of Americans could lose their health insurance, and rates for millions more could rise if the insurance markets collapse in the more than 30 states that use the federal insurance exchange.
The speech was something of a victory lap for a health care measure Mr. Obama argued has defied ''doom and gloom predictions'' and ''Chicken Little warnings'' of economic calamity and freedoms revoked. But it was also a preview of the sharp political rebukes the president is prepared to deal to Republicans should they seek to upend the law in the wake of an adverse ruling later this month.
Whether or not the court invalidates the subsidies, health care is almost certain to be a central issue in the 2016 presidential campaign.
The Affordable Care Act, Mr. Obama said, is no longer just a piece of legislation or an abstract theory, but ''a reality that people on the ground, day to day, are experiencing.''
''Their lives are better,'' Mr. Obama said. ''Americans support this new reality.''
Republicans were quick to counter Mr. Obama's speech even before it began, saying the president was divorced from reality and denying the negative effects of a health care overhaul they said had raised costs and caused some people to lose health coverage they liked.
''I imagine the families threatened with double-digit premium increases would beg to differ, as would the millions of families who received cancellation notices for the plans they had and wanted to keep,'' said Senator Mitch McConnell of Kentucky, the majority leader, calling the Affordable Care Act ''a law that's failed.''
''The sooner President Obama can get to grips with that reality, the sooner we can work together to replace the fear and anguish of Obamacare with the hope and promise of true health reform.''
The Republican Party sought to use the health law as a political weapon against the presumed Democratic presidential front-runner.
''Whether it's skyrocketing costs, canceled insurance plans, or the law's legal issues, the problems caused by Obamacare rest squarely at the feet of this president, Hillary Clinton and the rest of the Democrat party,'' Michael Short, a Republican National Committee spokesman, said in a statement responding to the president's speech.
In his speech Tuesday, Mr. Obama made a familiar case that the 2010 law has brought huge improvements to the lives of millions of people who had previously been unable to afford basic health care, or who could not obtain coverage because of pre-existing conditions.
He cited statistics showing that the law has helped slow the growth of health care costs, and noted that the five years since its enactment has coincided with the longest streak of private-sector job growth on record.
''The critics stubbornly ignore reality,'' Mr. Obama said.
The Supreme Court case centers on a provision in the law that seems to say subsidies are available only to people living where the insurance exchanges had been ''established by the state.''
Speaking on Monday in Germany before returning from a meeting with European leaders, Mr. Obama said he was optimistic that the justices would not invalidate the subsidies with a ''contorted reading'' of the Affordable Care Act and the intent of lawmakers.
''I'm optimistic that the Supreme Court will play it straight when it comes to the interpretation,'' he said. ''If it didn't, Congress could fix this whole thing with a one-sentence provision.''
In fact, Republicans are signaling another drawn-out political fight over fixing the health law if the court rules the subsidies are invalid. Senator John Barrasso of Wyoming, the chairman of the Republican Policy Committee, who called the law an ''expensive disaster,'' said Tuesday that members of his party ''aren't interested in a one-sentence fix -- unless that sentence is: 'Obamacare is repealed.' ''
Mr. Obama's speech was part of a broader effort to shape and define the president's biggest domestic accomplishment in the face of partisan attacks.
The White House also unveiled a new website intended to put the Affordable Care Act into a broader historical context. The site features a timeline suggesting that efforts to expand health coverage began more than 100 years ago.
Critics and doubters of the Affordable Care Act are unlikely to be swayed by the new promotional materials. But White House officials are hoping that Mr. Obama can make a convincing case that the law is working, and that it is here to stay, before he leaves office in 2017.
URL: http://www.nytimes.com/2015/06/10/us/obama-speech-affordable-care-act-supreme-court.html
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GRAPHIC: PHOTO: Saying it is ''now part of the fabric of how we care for one another,'' President Obama extolled the benefits of the Affordable Care Act in a speech Tuesday. (PHOTOGRAPH BY ZACH GIBSON/THE NEW YORK TIMES)
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(You're the Boss)
November 15, 2013 Friday
Obama Health Care Fixes Give Small Businesses Time to Assess
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1218 words
HIGHLIGHT: Many companies are choosing to renew existing policies so they can put off assessing the new Affordable Care Act-compliant policies.
For small businesses grappling with how the Affordable Care Act would affect their health insurance plans, the announcement on Thursday from the White House, delaying the transition to new rules by as much as two years, may come as welcome relief.
But small companies were never under the pressure that hundreds of thousands of people with individual insurance policies faced when they received notices canceling that insurance. Despite some predictions of a similar, imminent wave of mass cancellations, many small-business owners - perhaps most in some places - were making plans to renew their current policies early, allowing them to defer hard decisions on new plans until late next year. Whatever urgency those owners felt was the result of facing a deadline to make the decision to renew early by Dec. 1, or in some cases, Dec. 15. That deadline has now been extended.
"We're seeing significantly more than half of our customers shopping to see if an early renewal strategy is to their advantage or not," said Michael Gomes, a senior vice president at BenefitMall, an intermediary between individual independent insurance agents and insurance carriers that operates in 19 states and facilitates health insurance for about 150,000 small groups. "Almost every group is looking at it to see if it is to their advantage, and many are finding that it is."
Other general agents and independent agents reported similar findings. Russ Childers, an agent in Americus, Ga., said that all but one of his small-business clients renewed early. "We basically told folks, 'When in doubt, early renew,' " he said. If new plans that are compliant with the Affordable Care Act prove more attractive, he said, "we can always change."
Unlike in the individual market, where plans must be compliant with the requirements of the Affordable Care Act on Jan. 1, small group plans are required to meet the new standards only as old plans end and must be renewed, which can happen throughout the year. That has enabled insurers to offer small groups the opportunity to renew early, before the new rules take effect.
The main incentive for renewing early, according to agents, is simply to avoid rate increases. The Affordable Care Act's provisions limiting how much insurers can charge different plan participants benefit some groups but punish others - primarily those with younger, healthier employees. Under individual state rules that the Affordable Care Act supplanted, insurers could take into account factors like employees' age, health status, gender and the group's industry. The act pares the factors for rating policy-holders to tobacco use and age, and it limits premiums for the oldest adults to not more than three times the rate for the youngest adults.
"Most people are under the impression that people are trying to early renew to get around the law, and the additional mandates, but that's not necessarily true," Mr. Gomes said. "The majority of those that we're seeing renew early are those that had preferred rates, and they achieved those preferred rates because they had a healthy employee population. Now, by going to community-treated risk pools, they're the ones seeing the highest rate increases."
In Wichita Falls, Tex., Kelly Fristoe, an insurance agent, said the majority of his clients had also sought early renewals. "Where I live, we have a younger workforce, and that's where the increases are taking place," he said. "The majority of my business is under 45 years old, and they're seeing rate increases as well."
Mr. Fristoe said that most of his small-business customers had plans that already met the health law's requirements for minimum essential benefits coverage and cost-sharing. "Ten percent of the cost increase is based on plan-design changes," he said. "The other 90 percent is based on the transition to community rating."
In theory, the changes should help groups with older, sicker employees and hurt groups of younger, healthier employees. "When we talk to our carrier partners across the country, they always talk in terms of a third, a third, a third," Mr. Gomes said. "A third of the population will see significant rate advantage in early renewal - better than a 10 percent savings - a third would be crazy to renew early, and the middle third could flip either way."
But other agents said that in practice, rates would increases for many more small businesses under the new rules. David C. Smith, a broker in Fayetteville, N.C., said that fully three-fifths of his clients due to renew on Jan. 1 would have premium increases of at least 10 percent under the new rules, and a third of these would have premiums rise by more than 30 percent. In all, about 30 percent of those clients have renewed early, Mr. Smith said, and as a result, most of them have borne premium increases under 10 percent.
In California, which adopted many of the market reforms in the Affordable Care Act years ago, rates are likely to go up 15 to 20 percent under the new rules, said John Nelson, chief executive of Warner Pacific, a large general agency operating in California and Colorado. "It's a combination of factors," said Mr. Warner, whose affiliated agents write policies for 30,000 businesses, mostly in California. "It's not just one thing or another thing, and it all adds up." Among those factors, he said, was a sales tax on health insurance premiums included in the law.
In New Jersey, another state with fairly strict insurance regulations already in place, "everybody is testing the waters, regardless of the demographics of the group," by investigating early renewal, said David Mordo, a vice president with Walsh Benefits, a general agency based in the state. "They're doing it because they don't like the plan selections that carriers have come out with for 2014." Mr. Mordo said that as many as three-quarters of his agents' small-business clients could renew early.
Other agents posited much lower estimates for New Jersey and elsewhere. Reliable figures for early renewal do not appear to be available.
The change in rules announced Thursday by the White House allows insurance carriers to renew policies for one year under their current terms through Oct. 1, 2014 - provided businesses had those policies in place on Oct. 1, 2013. That means that businesses could have up until Oct. 1, 2015 to switch to new plans that comply with the Affordable Care Act. The government may extend the transition further. On the other hand, businesses that find new plans more advantageous can switch whenever they want beginning next year.
And just because the administration is permitting insurers to renew existing policies does not mean carriers will do so. Insurers "have invested time and money to revamp a portfolio of products in an effort to comply with the law," said Mr. Mordo. "They created new infrastructure, they created new technology.
"I can't see how they can go back and undo what they've already done," he said. "They have to be in a minor state of disarray."
A Business Owner's First Brush With HealthCare.gov
A Small Business Starts to Navigate the Affordable Care Act
Another Delay for Small-Business Health Exchanges? Depends on Whom You Ask.
Following Up on Our Sales Training, Profit-Sharing, Health Insurance and the Shutdown
Why Labeling Health Plans Gold, Silver or Bronze Doesn't Help
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July 2, 2012 Monday
How Much Would the Medicaid Expansion Cost Your State?
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 310 words
HIGHLIGHT: A state-by-state calculation of the state and federal funds that would be required in the first six years to meet the goals of the Affordable Care Act -- an expansion that some governors have renounced.
The 50 statehouses have become the next major battleground for the Affordable Care Act, President Obama's health care law.
Last week's Supreme Court decision held that each state could choose whether to extend Medicaid coverage to all adults living within 133 percent of the poverty line - an expansion that could add as many as 17 million previously uninsured people to the Medicaid rolls. The federal government would cover a vast majority of the new costs, but strapped states would need to kick in some money, too.
Some governors, like Martin O'Malley, Democrat of Maryland, have indicated they will say yes. Other governors, including a number of Republicans, have said they will say no.
But will it be a good deal for the states to take the money and cover more people?
I created a chart to show how much a state would have to spend in dollar terms and as a percentage of its 2011 economic output to expand coverage between 2014 and 2019. (The cost estimates come from the indispensable Kaiser Family Foundation, and the state output estimates come from the Bureau of Economic Analysis.) I also added in how much the federal government would spend in a state if it chose to expand coverage, again in dollar terms and as a percentage of the given state's economic output.
A few states would actually save money - meaning their new spending would be negative. Those states already have relatively broad Medicaid eligibility, and would have to spend less as the federal financing in the Affordable Care Act kicked in. (For more on how that works, see this Kaiser study.)
You can check your state out in the table below, created with the help of the graphics designer Alicia Parlapiano.
Could States Save by Expanding Medicaid?
Alternatives to the Mandate
In a Crisis, Rethinking Fiscal Federalism
Medicaid Expansion and Jobs
Health Care: Solidarity vs. Rugged Individualism
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(First Draft)
June 25, 2015 Thursday
Republicans in Congress Ponder Next Move on Health Care
BYLINE: JONATHAN WEISMAN
SECTION: US; politics
LENGTH: 429 words
HIGHLIGHT: The Republicans’ possible choices after the Supreme Court ruling: Try to do something modest that could overcome a presidential veto, or press forward with a true replacement for the Affordable Care Act.
The Supreme Court's decision on the Affordable Care Act subsidies left Republicans in Congress badly divided on their next steps.
This year, the House and Senate approved a budget that included the same parliamentary twist that helped secure the Affordable Care Act's passage. So-called "reconciliation" would allow Republicans to pass major health care changes that cannot be filibustered in the Senate - as long as those changes impact the government's spending and revenue.
If the court had sided with the plaintiffs, Republicans had hoped to force President Obama to negotiate a new health care law more to their liking. Now, any significant legislation will simply be vetoed, Republicans conceded.
That leaves them with a decision: Try to do something modest that could overcome a veto, or press forward with a true replacement for the Affordable Care Act? House Republicans vowed to press forward.
"The president's made it clear he's not signing anything, even bipartisan bills," said Representative Kevin Brady, Republican of Texas and a leading health care legislator on the House Ways and Means Committee. "He will continue to be an obstructionist, so we are going to have to focus on what we think is right."
Lawmakers can make changes to the health care law's tax increases and spending provisions, but they cannot make policy changes that do not impact the government's finances, like regulations on the insurance market, and possibly the mandates on health care coverage Republicans dislike the most.
Representative Tom Price, Republican of Georgia and the chairman of the House Budget Committee, who wrote the "reconciliation" language, said he would press forward with a full replacement of the A.C.A.
"The goal is to get the American people to speak loudly enough through their representatives to get this administration moving in the right direction," he said.
But it was also clear the court ruling would slow that process. And Senate Republicans were not nearly as enthusiastic.
"I wouldn't want to say anything is fruitless because around here you do what you can do at the time you can do it," said Senator Charles E. Grassley of Iowa, one of the small group of Republicans who tried to write the health care law before ultimately abandoning it.
Representative Pete Sessions, Republican of Texas and one of the leadership's point people in preparing for the decision, said he would introduce draft legislation to replace the A.C.A. But, he said, that would only begin the discussion.
"We're not going to do what the Democrats did and ram this through," he said.
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January 1, 2017 Sunday
Late Edition - Final
Job No. 1 When New Congress Meets? Dismantling Obama's Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 907 words
WASHINGTON -- Congress often waits for a new president to take office before it gets down to business. This year, Republicans will drop that custom in their dash to scrap the Affordable Care Act.
Within hours of the new Congress convening on Tuesday, the House plans to adopt a package of rules to clear the way for repealing the health care law and replacing it with as-yet-unspecified measures meant to help people obtain insurance coverage.
Then, in the week of Jan. 9, according to a likely timetable sketched out by Representative Greg Walden, Republican of Oregon, the House will vote on a budget blueprint, which is expected to call for the repeal of the Affordable Care Act.
Later, in the week starting Jan. 30, said Mr. Walden, incoming chairman of the House Energy and Commerce Committee, the panel will act on legislation to carry out what is in the blueprint. That bill would be the vehicle for repealing major provisions of the health care law, including the expansion of Medicaid.
Republicans in both houses of Congress have said that repealing the health law is a top priority for the first months of 2017. ''The Obamacare repeal resolution will be the first item up,'' said the Senate majority leader, Mitch McConnell, Republican of Kentucky.
President-elect Donald J. Trump has called the law an ''absolute disaster,'' and has said he is eager to sign a repeal bill like one vetoed by President Obama in early 2016.
Representative Nancy Pelosi of California, the House Democratic leader, said the rules devised by House Republicans were ''their opening salvo'' against a law that she said had been ''successful in meeting its goals of reducing cost, increasing access and improving quality of care.''
In a last-ditch bid to save his signature legislative achievement, which has provided coverage to some 20 million Americans, Mr. Obama plans to visit a meeting of House and Senate Democrats on Wednesday to rally support for the law.
The Affordable Care Act, approved in 2010 without any Republican votes, provides tax credits to help people buy private insurance. It also allowed states to expand Medicaid eligibility, with the federal government paying most of the cost for new beneficiaries.
The law also saves hundreds of billions of dollars by reducing the growth of Medicare payments to hospitals, nursing homes, health maintenance organizations and other health care providers. Repealing the law would eliminate those savings and thus increase federal spending, the Congressional Budget Office says.
The proposed rules written by House Republicans allow lawmakers to raise a point of order against legislation that causes an increase in certain types of federal spending. But the rules give special protection to bills repealing or ''reforming'' the Affordable Care Act, even if such bills cause a temporary increase in spending.
Republicans worry that the Congressional Budget Office could count their plan for replacing the law as new spending, making it subject to challenge on the House floor. The exception being written into House rules would help them avoid that possibility.
Ms. Pelosi pointed to this provision as evidence that the health care law, as written, saves money. In their version of the rules, she said, ''Republicans are admitting that repealing the Affordable Care Act will increase costs.''
The Congressional Budget Office said in 2015 that ''repealing the A.C.A. would raise federal deficits by $137 billion over the 2016-2025 period'' -- not only because the government would spend more on Medicare, for older Americans, but also because it would collect less in taxes from high-income households.
The 2010 law, the budget office noted, increased the payroll tax rate for many high-income taxpayers and imposed a surtax on their net investment income. The law also imposed annual fees on health insurers and manufacturers of brand-name drugs and medical devices.
Republicans may want to hold on to some of the tax revenue and Medicare savings, to help offset the cost of their plan to replace the Affordable Care Act. They have been trying to devise that replacement, but do not have a consensus and may hold hearings to examine the options.
If Congress votes to repeal the health care law early in 2017, Republican leaders say, they may delay the effective date for several years, to avoid disrupting coverage for people who have recently gained it.
The Republican rules package would also allow the House to continue its legal challenge to spending on insurance subsidies that reduce out-of-pocket costs for more than six million Americans.
In addition, the rules would require House committee chairmen to propose ways of imposing more fiscal discipline on federal entitlement programs. In the jargon of the federal budget, the goal is to switch some programs from ''mandatory funding'' to ''discretionary appropriations,'' over which Congress has greater control.
This rule mirrors ideas advanced by Representative Tom Price, Republican of Georgia and chairman of the House Budget Committee, whom Mr. Trump has selected to be his secretary of health and human services.
''Two-thirds of current expenditures are dedicated to a relatively small number of automatic spending programs like Medicare, Medicaid and Social Security, which are not subject to annual appropriations and therefore operate largely outside the control of Congress,'' Mr. Price said in a recent speech.
URL: http://www.nytimes.com/2016/12/31/us/politics/obamacare-congress.html
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GRAPHIC: PHOTO: Mitch McConnell, the Senate majority leader, has said that repealing the Affordable Care Act was the new Congress's top priority. (PHOTOGRAPH BY MARK WILSON/GETTY IMAGES) (A16)
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November 14, 2016 Monday 00:00 EST
What Could Be Worse Than Repealing All of Obamacare?;
Op-Ed Contributor
BYLINE: JONATHAN GRUBER
SECTION: OPINION
LENGTH: 782 words
HIGHLIGHT: By keeping only the most popular parts, Donald Trump would leave patients worse off than they were before the law was passed.
Donald J. Trump made headlines on Friday by saying he would like to keep two components of the Affordable Care Act: allowing young people to stay on their parents' insurance until age 26, and continuing the ban on the exclusion of pre-existing conditions by insurers.
These have long been staples of proposed Republican replacements for the act, but their reaffirmation by the president-elect heightens the importance of understanding what these provisions do, and what they don't.
The ability of young adults to stay on their parents' insurance provided real benefits. It increased coverage by roughly a million people, and improved young people's health. Maintaining this provision is a clear part of any sensible replacement for the Affordable Care Act, and Mr. Trump can do it.
Keeping the ban on insurance companies excluding people with pre-existing conditions, however, is a different story. The problem these patients faced was one of the most pernicious flaws of the individual insurance market pre-Obamacare; their exclusion essentially undercut the entire notion of insurance. How is a breast-cancer survivor meaningfully insured if any costs associated with the recurrence of her cancer, expenses that could run into the hundreds of thousands of dollars, are not covered? So it sounds encouraging that Mr. Trump would continue to ban this behavior.
But let's not kid ourselves. Maintaining this popular provision while scrapping the rest of the health care law would be worse for people with pre-existing conditions than repealing the law in its entirety.
To understand why, let's go back to the world of individual insurance before the major provisions of the Affordable Care Act went into effect on Jan. 1, 2014. In that world, the primary source of profit for insurers was not providing better care so that patients stayed healthy, or negotiating better prices with hospitals and drug companies; it was their ability to avoid the sick and insure only the healthy. And insurers had three tools for doing so: denying coverage to the insured for any costs associated with pre-existing conditions; denying insurance entirely to sick people; and charging the sick much higher prices than the healthy, a practice called health underwriting.
If Mr. Trump preserves just the ban on the first of these tools, and allows insurers to reintroduce the other two, he has effectively done nothing. That's because any insurer can simply use the other tools to accomplish the same goal as it could with all three.
Suppose a breast-cancer survivor applied for insurance in Mr. Trump's post-Obamacare world. It's true that the insurer could not offer her coverage that didn't include breast-cancer treatments. But the insurer could simply not sell her coverage at all.
Alternatively, the insurer could offer coverage, but say that any breast-cancer survivor had to pay, say, five times more than everyone else. Both would be perfectly legal if the Affordable Care Act was repealed and replaced under Mr. Trump's principles. If we say that insurers have to pay for breast-cancer treatment for their insured, but allow them to set unaffordable prices or deny insurance altogether, how does that solve the problem?
In fact, Mr. Trump's idea would make insurance markets function even worse than they did before Obamacare. Back then, an otherwise-healthy breast-cancer survivor could at least get insurance coverage for medical expenses not related to her cancer. If Mr. Trump followed through with his suggestion, that would not be possible: The insurer would simply deny coverage altogether rather than take the risk of being forced to pay for treatment for a recurring breast cancer.
So Mr. Trump would not only continue the insurance discrimination that plagued the country before the Affordable Care Act but even make it worse.
In fact, there is simply no Republican replacement for the act that wouldn't leave millions of Americans at serious financial risk. The single most important accomplishment of the Affordable Care Act was to bring the United States into line with the rest of the developed world, as a place where people were not one bad gene or one bad traffic accident away from bankruptcy.
Mr. Trump and other Republicans can discuss kind-sounding alternatives as much as they like, but they can't hide the fact that repealing the fundamental insurance protections that are central to the act would be a cruel backward step.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTOpinion), and sign up for the Opinion Today newsletter.
Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology, was a health care consultant for the Obama administration.
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March 23, 2012 Friday
Could This Be the End of Health Care Reform?
BYLINE: EZEKIEL J. EMANUEL
SECTION: OPINION
LENGTH: 1012 words
HIGHLIGHT: No matter how the court rules on the individual mandate, progress will continue.
What if the Supreme Court declares unconstitutional the Affordable Care Act's requirement that everyone buy health insurance? What if it strikes down all the act's insurance provisions, including the requirement that insurance companies cover everyone, regardless of pre-existing illnesses? Would this totally put an end to the health care reforms we have passed in the last three years?
Absolutely not.
The essence of the case the Supreme Court will begin hearing on Monday is whether, invoking its powers in the commerce clause of the Constitution, Congress can require individuals to purchase health insurance or pay a penalty. I believe the mandate is constitutional, but no matter how the court rules, many health care reforms that were approved by Congress through the Affordable Care Act and other recent bills - like those to promote electronic health records, encourage coordinated care, reduce medical errors and cut costs - will proceed.
Tens of thousands of Americans die because of hospital-acquired infections every year, and far more are harmed by medical errors. Last year, authorized by the Affordable Care Act, the Obama administration announced a $500 million program called Partnership for Patients aimed at reducing hospital-acquired infections, errors and other preventable complications. The act also requires Medicare to begin posting online each hospital's rate of certain medical errors and infections, and to cut payments to hospitals with the highest rates.
Consequently, hospitals across the country are working to reduce preventable hospital errors. Once it's clear that this is a major priority, significant progress can be made. A few years before the health care reform act was passed, the Hospital of the University of Pennsylvania, where I work, started paying attention to reducing preventable errors, and it managed to reduce infections from intravenous lines to 1 or fewer per month from 30 to 40 per month. All it took was removing intravenous lines whenever they weren't necessary, changing them regularly and using a more vigorous sterilizing technique when inserting them. Many other institutions are making similar progress now. All of this has nothing to do with the constitutionality of the individual mandate and will continue no matter what the Supreme Court rules.
The same goes for the problem of hospital readmissions. Right now, nearly 20 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days. Some are scheduled readmissions; others occur for completely unrelated health problems, like falls and accidents. But many could be prevented by paying more attention to the coordination of care between physicians and hospitals and by better follow-up after patients are discharged. Beginning this year, the health care reform act will penalize hospitals that have high readmission rates for three conditions: pneumonia, heart failure and heart attacks. This list will later be expanded. As a result, all hospitals are now scrambling to figure out how to create "the perfect patient discharge" so patients don't become hospital "frequent fliers."
Other progress is being made that will not be affected by a court ruling on the mandate. Thanks to the act, there has been a growth of accountable care organizations - groups of physicians and hospitals that come together to deliver coordinated care at a lower cost and to share in potential savings. Many health policy experts think these organizations are our best hope to improve care and lower costs.
The act also lays the groundwork for a more efficient payment system. Today, payment for a knee replacement, for example, is à la carte: fees for the orthopedic surgeon, the anesthesiologist, the radiologist, the hospital and operating room and the physical therapist are all paid separately. Under the health care reform act, Medicare is instructed to conduct 10 pilot programs with "bundled payments," in which there is one fixed price for the whole episode of care. Preliminary data suggest that bundled payments can produce significant efficiencies and cost savings, and improved quality through better coordination of care.
And a few reforms that have nothing to do with the Affordable Care Act will continue as well. The American Recovery and Reinvestment Act - the 2009 stimulus - contained provisions to promote the expansion of electronic health records, which allow physicians to more closely track patients, especially the chronically ill, and enable the seamless exchange of data among multiple physicians, hospitals and other providers. In just the few years since, there has been tremendous progress: before, just 16 percent of hospitals had electronic health records; now 35 percent have them. Before, 17 percent of doctors used electronic records in their offices; now 34 percent do.
Of course, one big thing will change if the court rules the individual mandate unconstitutional: Instead of the 32 million Americans predicted to gain coverage under the health insurance reform act, only around 16 million Americans would gain coverage. Even with subsidies for buying insurance, some healthy people would opt out of the state health insurance exchanges authorized by the act. This would drive up premiums by an estimated 15 to 20 percent and push more healthy people out of the market, creating a downward spiral until the only people buying insurance are those who are very sick. While many states may still try to move forward with their exchanges without the mandate, they will eventually collapse.
If the Supreme Court rules that the individual mandate is unconstitutional - in my opinion, an improbable and legally indefensible decision - it will not end health care reform. Hospitals and doctors will continue to work to improve care and control costs. But tens of millions of Americans will continue to be excluded from the health care system, which is hardly an optimal outcome.
Never Before
Rick Santorum Still Isn't Crazy
It's Moderately Super Wednesday!
Rick Santorum Isn't Crazy
Should Obama Have His Own Plan B?
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May 1, 2013 Wednesday
Health Coverage Worthy of a Senator
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 745 words
HIGHLIGHT: A provision forcing members of Congress to get their health insurance under the exchanges set up by the Affordable Care Act may prompt them to make such coverage too attractive, and ultimately weaken the system, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
To promote economic efficiency and the goal of universal health coverage, perhaps members of Congress should not be required to enroll in the new insurance exchanges.
The Affordable Care Act of 2010 seeks to invigorate the nongroup health insurance market - that is, health insurance that people can buy without going through an employer - by creating and subsidizing insurance exchanges similar to the one created by Massachusetts in 2007. In addition, the law seeks to make health insurance affordable for middle-class families by having the federal government pay part of premiums and out-of-pocket costs, but only for people buying nongroup health insurance through the new exchanges.
A provision of the law known as the Grassley amendment requires members of Congress and their staffs to obtain their own health insurance through the exchanges. The amendment gives the authors of the law, and the authors of future tweaks of the law, a personal stake in the success of the plans to be provided through the new exchanges.
Because members of Congress are accustomed to high-quality medical care provided to them through federal employee benefit programs, one might expect that they would push for top quality care to be delivered through the exchanges too. That is one reason why an (ultimately unfounded) report that the Grassley amendment might be reversed prompted so much outrage. (What's actually at issue is uncertainty over whether the employer contributions in the current health plan for those on Capitol Hill can be applied to coverage through the exchanges.)
But the possibility that middle-class families could obtain care that is both top quality - good enough for your senator - and subsidized creates a number of economic problems. It gives employers a stronger incentive to drop their coverage, because employers and their employees can take comfort in the prospect that the alternative to employer insurance is a health plan that is good enough for your senator.
If the exchange plans were good enough, people who are rushing to find a job, and people considering leaving their job, would no longer have to see employment as their only means of obtaining top quality, subsidized coverage. As a result, some of those would work less (see the Congressional Budget Office on some of health reform's work incentives, and a 1994 explanation from Alan Krueger and Uwe E. Reinhardt).
The more attractive the subsidized plans are, the more people will join them, and the greater the costs to the federal government. If the Affordable Care Act proves to be too expensive, drastic steps may result, such as closing enrollment in the subsidized exchange plans or repeal of the law all together. Either result would mean that the law's objectives would go unmet.
There is an alternative approach, pursued in Massachusetts, for those not covered through an employer, a spouse's employer, or Medicaid or Medicare. They may be eligible to join one of several subsidized plans under the state's Commonwealth Care program (most are operated by the Medicaid managed care organizations), but those are less desirable than the plans typically offered by employers. With that as the alternative for their middle-class employees, employers would be discouraged from dropping coverage. People would have an incentive to work, because that's where the best plans would be available.
Massachusetts did not have anything like the Grassley amendment.
For these reasons, economists have long recommended that subsidized goods be of somewhat lower quality than goods available without subsidy. Massachusetts followed that advice, and found that (a) their health reform approach significantly reduced the number of uninsured and that (b) less than 10 percent of the people in Massachusetts whose family income fell in the subsidy-eligible range chose to participate in the subsidized plans.
Although politically incorrect and perhaps unfair, allowing members of Congress to keep their federal employee coverage might be the best thing for universal coverage and reducing the impact of the Affordable Care Act on the federal budget.
Health Reform, the Reward to Work and Massachusetts
Hammurabi's Code and U.S. Health Care
The Senate Acts
Small Companies and the Affordable Care Act
In Massachusetts We Trust
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January 3, 2014 Friday
Medicare Advantage and the 'Theft' of $156 Billion
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1264 words
HIGHLIGHT: Changes to payments to Medicare Advantage plans introduced by the Affordable Care Act are more equitable for all taxpayers, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
In a Dec. 27 lead editorial, "Government Advantage," the editorial writers of The Wall Street Journal wrote:
Amid the larger ObamaCare meltdown, seniors are discovering their choices are fewer, costs higher and coverage poorer too. Liberals fear the increasing popularity of Medicare Advantage, and they're starting to gut this market alternative to their original health care entitlement before the sand runs out on President Obama's second term. About 14 million people or 28 percent of Medicare beneficiaries choose Advantage over the government option, which is why the Affordable Care Act steals about $156 billion from the program - even as enrollment has surged 30 percent since 2010.
A theft of $156 billion should catch one's attention, especially if government is the thief. It warrants a closer look.
For starters, what is the time frame of this $156 billion "theft"? Greater clarity on this point would have been helpful, lest readers think that this is an annual figure. In fact, it is the sum of projected future annual cuts off projected future total payments to Medicare Advantage plans over the decade 2013-2022 (see line 8 of Table 2, page 5 in this Congressional Budget Office projection).
That point aside, what the Affordable Care Act has done to the Medicare Advantage plans lies, like beauty, in the eyes of the beholder.
The story begins with the Medicare Prescription Drug Improvement and Modernization Act of 2003, which revamped the manner in which Medicare paid private health plans for Medicare beneficiaries who chose them in lieu of traditional Medicare. The program, called Medicare Risk when it was established in 1982 and rechristened Medicare+Choice in 1997, was reborn as Medicare Advantage.
I described and discussed the complicated administrative payment algorithm prescribed for Medicare Advantage by that law in a previous post. Those interested in the modus operandi of the payment system for Medicare Advantage before the Affordable Care Act of 2010 can read an official description by the Medicare Payment Advisory Commission of Congress (known as Medpac), dated October 2008. A description of the current payment system is also available.
Suffice it to note here that, on average, the payment method prescribed by the 2003 law, which took effect in 2006, has cost taxpayers substantially more per Medicare beneficiary who enrolled in a Medicare Advantage plan than these beneficiaries would have cost taxpayers in traditional Medicare. That is because Medicare has paid private plans more per beneficiary than these beneficiaries would have cost in traditional Medicare.
For the most part, these extra payments have not landed in the private plans' profits. Instead, the plans have been required to offer Medicare beneficiaries either added benefits for those extra payments or reduced premiums for the Part B and Part D coverage that Medicare beneficiaries are required to buy under Medicare Advantage plans or traditional Medicare.
But the extra payments and the added benefits did give the private plans a competitive advantage compared with traditional Medicare in the market for enrollees. In effect, the 2003 law rewarded Medicare beneficiaries opting for a private health plan with more tax-financed benefits than were available to similar beneficiaries choosing to stay in traditional Medicare and even forced the latter to help finance the bonus granted the Medicare Advantage enrollees through higher out-of-pocket Part B premiums. That may not seem equitable, but it appears to have been the lawmakers' intent.
Certainly the Medpac commissioners - a group of savvy policy analysts and private stakeholders in American health care - have deemed this payment method unfair. As they noted (see Page 252) in their March 2009 report, referring to Medicare Advantage as M.A. and traditional Medicare as F.F.S.:
In 2009, payments to M.A. plans continue to exceed what Medicare would spend for similar beneficiaries in F.F.S. M.A. payments per enrollee are projected to be 114 percent of comparable F.F.S. spending in 2009, compared with 113 percent in 2008. This added cost contributes to the worsening long-range financial sustainability of the Medicare program. ... In aggregate, enhanced benefits [offered by the M.A. plans] are funded by the taxpayers and all beneficiaries (whether they belong to M.A. plans or not), rather than being funded through savings achieved as a result of plan cost efficiencies. In addition, a portion of the value of enhanced benefits consists of funds for plan administration and profits and not direct health care services for beneficiaries.
Similarly, in their 2010 report, the Medpac commissioners noted: "In 2009, Medicare spent roughly $14 billion more for the beneficiaries enrolled in M.A. plans than it would have spent if they had stayed in F.F.S. Medicare. To support the extra spending, Part B premiums were higher for all Medicare beneficiaries (including those in F.F.S.)."
The commissioners added (see Page 260) that the Centers for Medicare and Medicaid Services
estimated that the Part B premium was $3.35 per month higher in 2009 than it would have been if spending for M.A. enrollees had been the same as in F.F.S. ... The Commission supports financial neutrality between F.F.S. and the M.A. program. Financial neutrality means that the Medicare program should not pay M.A. plans more than it would have paid for the same set of services under F.F.S. Currently, Medicare spends more under the M.A. program than under F.F.S. for similar beneficiaries. This higher spending results in increased government outlays and higher beneficiary Part B premiums (including higher premiums for beneficiaries in F.F.S.) at a time when both the Medicare program and its beneficiaries are under increasing financial stress.
Prompted no doubt by these repeated recommendations from the nonpartisan Medpac, the drafters of the Affordable Care Act introduced the following changes in the payment formula for Medicare Advantage:
(a) Gradually moving the overall average (risk-adjusted) payments per beneficiary to the Medicare Advantage plans toward neutrality with traditional Medicare;
(b) Gradually reducing payments to the plans in counties with high per-beneficiary costs under traditional Medicare (on the theory that economies there should be more easily achievable for the private plans), but lifting the payments above per-beneficiary costs under traditional Medicare in low-cost counties;
(c) Within those constraints, rewarding the plans explicitly with higher payments for higher, measured quality.
Now, one can easily understand why The Wall Street Journal editorial writers, given their ideological predilections and the point they sought to make, would not mention the extra payments hitherto made to Medicare Advantage plans and simply portray the payment change under the Affordable Care Act as theft.
On the other hand, one can also easily see why designers of the Affordable Care Act saw in their new payment formula not a theft from the Medicare Advantage plans nor their destruction through "fiscal starvation," as The Wall Street Journal portrays it, but, like the commissioners on Medpac, a leveling of the playing field in that competitive market.
I share that view.
A Conservative Alternative to Obamacare
The Hurdles to Success for the Affordable Care Act
Medicare's Lessons for the Affordable Care Act
The Complexities of Comparing Medicare Choices
The Wyden-Ryan Plan: Deja Vu All Over Again
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October 29, 2013 Tuesday
Kentucky's Senators Versus Kentuckians
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 208 words
HIGHLIGHT: Senators Mitch McConnell and Rand Paul hate the Affordable Care Act. But their state may have built the best health insurance site around.
Senator Rand Paul of Kentucky hates the Affordable Care Act. So does Kentucky's senior senator, Mitch McConnell - though apparently not quite enough to stave off a primary fight. The Senate Conservatives Fund has endorsed Mr. McConnell's Tea Party challenger, Matt Bevin, who charged in a television spot that "McConnell helped Barack Obama and Harry Reid fund Obamacare." By that he meant that Mr. McConnell worked to end the government shutdown and raise the debt ceiling to avoid default.
And yet, with this bickering in the background, Kentucky has been unusually successful in rolling out its health insurance marketplace. Dylan Scott wrote in Talking Points Memo yesterday that "more than 26,000 people have enrolled in coverage, more than 50,000 have started applications and more than 300,000 unique visitors have checked out what the marketplace has to offer." That's in a state where roughly one in six are uninsured.
Kentucky, in Mr. Scott's formulation, may have "built the country's best Obamacare Website."
The question is, will the disconnect between Kentuckians' actual experience with the Affordable Care Act, and what their senators say about the Affordable Care Act, matter in the next election? Could Mr. Bevin's strategy backfire?
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December 11, 2013 Wednesday
Conflicting Pressures on Demand for Doctors
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 961 words
HIGHLIGHT: Some provisions of the Affordable Care Act could reduce the use of medical services, but others could lead to a doctor shortage, by increasing demand and limiting payments, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The supply and demand for health services will experience a variety of changes in the near future, especially those from the Affordable Care Act. But nobody has quantified their net impact on the market for doctors. The new law pushes demand for physicians in both directions, making it is easy for advocates on either side of the law to cherry-pick provisions they support.
The law is beginning to build new markets for individual insurance policies that in some ways can reduce the demand for health care and doctors.
Participating families above 250 percent of the poverty line will, on average, pay 30 percent of their medical expenses out of pocket, as compared with the 17 percent out of pocket that is typical for employer-sponsored health plans. That gives patients almost twice the incentive to avoid using doctors or to seek treatments that are less expensive and likely less physician-intensive.
In some states, patients are being pushed toward less physician-intensive care because the insurance plans offered on the exchanges have narrower networks that exclude some of the more expensive facilities. Some of these excluded providers may be considered among the best in the industry, because state regulators seek to keep insurance premiums low. This is a force that could help limit the demand for doctorss in narrow-network states.
Other states include their top facilities in the networks accessible by residents who buy their insurance on the exchanges and do not have this force limiting physician demand. Moreover, the broad-network states will likely pull dcotorss away from the narrow network states where demand for them is less.
Although the new law pushes the insured to shoulder a larger share of their health expenses, the law also mandates that insurance pay for a wider range of health goods and services. That mandate by itself could increase the demand for doctors.
The Affordable Care Act is supposed to increase the fraction of the population with health insurance, and it will in the long run because of the individual mandate, the large insurance subsidies and Medicaid expansions in a number of states. (In the short run, the act is reducing the number of people with health insurance, as many longstanding policies have been canceled because they do not conform with the new law.)
It is a mistake to assume that every person getting insurance coverage is an additional person demanding health care, because many of the so-called uninsured are actually insured in one way or another. Take Medicaid enrollment, for example. Sixteen million people were not enrolled in Medicaid in June 2010 yet participated in the program at other times during the fiscal year, largely because they don't bother enrolling (or know that they can) when they are healthy and turn to it only when need arises.
If and when those who are eligible but unenrolled make contact with hospitals and other providers - when they actually need the coverage - they are reminded to enroll. In an economic sense, these 16 million were, in effect, insured all along, despite their absence from the official statistics. The new law's individual mandate encourages some of these people to be perpetually enrolled, even when they are healthy, which is more a change in their official classification than a change in their use of health care.
The numbers of slots in medical schools and residency positions, and rules that permit nurses to perform a wider range of services, have important effects on the incomes of doctors, because easier entry into the medical profession reduces physician incomes. I'm not sure that the new law does much to change these entry barriers, though.
Proponents of the Affordable Care Act can point to the provisions that reduce physician demand and help prevent a doctor shortage; opponents can say that more insurance means more demand on an already strained profession.
A good economist should be able to examine all the provisions and tell us the net result. But none have done this. The most we have in terms of a comprehensive calculus of health reform and the demand for physicians is the example of Romneycare from Massachusetts, which Scott Gottlieb and Ezekiel Emanuel hold up as proof that there will be no doctor shortage.
But Romneycare is a different law than the Affordable Care Act and covered a different population. Even without those differences, Massachusetts could increase health care in the state in part by pulling in medical professionals from elsewhere in the nation.
The Affordable Care Act cannot do the same, except to pull medical professionals from abroad, where the barriers to moving are much greater.
If only the payments to physicians were free to adjust in response to the law, entry barriers, demographics and other forces, there would be neither a shortage nor a glut in the sense that doctors would be available to whoever would pay the market price and positions would be available for qualified doctors willing to work for that price.
But the new law limits payments to physicians and other medical providers. If patients are lucky, the demand for doctors will be low enough that the limits will not matter. But if the new law results in a significant net increase in physician demand, the payment limits will help remind us of Soviet-era limits on the price of bread, with queues and black markets to follow.
Hammurabi's Code and U.S. Health Care
Medicaid and the Incentive to Work
The Hurdles to Success for the Affordable Care Act
Waste vs. Value in American Health Care
Having More Doctors Might Reduce Health Spending. Or Maybe Increase It.
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March 15, 2017 Wednesday
Late Edition - Final
C.B.O. Analysis: Republican Health Plan Will Save Money but Drive Up the Number of Uninsured
BYLINE: By HAEYOUN PARK, K. K. REBECCA LAI, JUGAL K. PATEL and SARAH ALMUKHTAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 943 words
The Republican health care plan being considered by Congress will significantly increase the number of uninsured people, but it will save the federal government hundreds of billions of dollars, according to an analysis by the Congressional Budget Office. Here are the key findings from the report.
While President Trump promised ''insurance for everybody,'' the C.B.O. projects that if the Republican plan took effect today, 14 million more people would be uninsured next year, and by 2026, the number of uninsured would be about double what it is today. That means that in 10 years, the number of uninsured Americans would be closer to what it was before the Affordable Care Act, President Barack Obama's signature health law, took effect. Several prominent changes under the Republicans' proposal would cause fewer people to have insurance. It would substantially cut funding for Medicaid, which covers low-income Americans, and reduce the value of tax credits that individuals use to buy health insurance, pricing many out of the market. It would also repeal the individual mandate, which requires all Americans to obtain health insurance if they can afford it, or else face penalties. The mandate, which many Republicans criticize, was created to keep insurance affordable for those who are older or sick. Without the mandate, many healthy people are expected to drop coverage, driving up prices for those who need it most, and ultimately causing even more people to drop out of the individual market. To calculate how many people would be uninsured under the Republican plan, the C.B.O., a nonpartisan agency of economists and statisticians, also had to estimate what would happen if the Affordable Care Act were not repealed. The report concluded that after 10 years, the Republican plan would create 24 million additional uninsured people -- the difference between the number of uninsured under the proposed plan and the number if the Affordable Care Act is not repealed.
The Republican plan would save the federal government $337 billion by 2026, with the largest savings coming from cuts to Medicaid spending as well as reduced spending on tax credits for middle-income insurance buyers. The savings would have been substantially larger, but Republicans would also eliminate about $600 billion in taxes imposed under the Affordable Care Act, including taxes on investment income, prescription drugs and indoor tanning.
About two million fewer people will be covered through work in 2020 under the Republican plan. By 2026, that number will be seven million, according to the C.B.O. That's largely because fewer employers would offer coverage with the repeal of the employer mandate, which required large employers to offer affordable health insurance. But the C.B.O. estimates that some of those people would be able to buy their own insurance in the individual market.
The largest group of people to be affected by the Republican plan would be those with Medicaid coverage. Most of the declines would start in 2020, when the changes to the program would take effect. Under the current health care law, 31 states and the District of Columbia expanded Medicaid to cover low-income Americans without children, a group that previously found it difficult to afford insurance. Several states that expanded their Medicaid programs could reverse course if the Republican plan became law. The Republican plan does not repeal the expansion but would reduce funding for enrollees who gained access to Medicaid under the Affordable Care Act. The proposed plan would also limit funding for all enrollees by giving states a fixed sum per enrollee, rather than making an open-ended commitment to provide funding based on need. Republican leaders have long argued that fixing federal funding for Medicaid would ultimately produce significant savings in the federal budget, and the C.B.O. estimates that changes to Medicaid would decrease direct spending by $880 billion over 10 years.
Republican lawmakers cite rising premiums as a main reason for repealing the Affordable Care Act. The C.B.O. estimates that after an initial rise in average premiums, there would be an overall decrease beginning in 2020. By 2026, average premiums would be about 10 percent lower than under the current law. But the change in premiums would be significantly different, depending on age, because the Republican plan calls for charging more for older Americans than allowed under the current law. One of the biggest reasons premiums will go down is because insurance will become expensive for older people, causing them to leave the market, improving the risk pool. Under the Republican plan, the premium for a typical low-income 64-year-old, after subsidies, would jump to $14,600 a year, from $1,700 a year, but rise only slightly for a 40-year-old with the same income. While premiums have risen under the current law, it shielded many Americans from increases because a majority of those buying insurance through the marketplaces received tax subsidies from the federal government. The subsidies were on a sliding scale according to income, to help offset some of the costs for middle-income Americans. The Republican plan, however, changes the way premium subsidies are calculated: they would be distributed by age, instead of income. That means that middle-income Americans earning just above the cutoff for Obamacare subsidies would get substantially more help paying for their health insurance. But experts say that tax credits for those earning more won't have a meaningful effect in reducing the number of uninsured because most high earners are already insured anyway.
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GRAPHIC: CHARTS: Number of uninsured if the current health law is not repealed
Projected cumulative change in deficit under the Republican plan
Number of people who would lose Medicaid coverage under the Republican plan
Net premium for a single individual with annual income of $26,500
Net premium for a single individual with annual income of $68,200
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March 27, 2017 Monday
Late Edition - Final
After Death of Health Care Bill, Some Lawmakers Reach Across the Aisle
BYLINE: By ROBERT PEAR and MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 1573 words
WASHINGTON -- The sudden death of legislation to repeal the Affordable Care Act has created an opening for voices from both parties to press for fixes to the acknowledged problems in President Barack Obama's signature health law, as lawmakers and some senior White House officials appealed for bipartisanship.
But the White House, still smarting from a disastrous defeat on Friday, appeared uncertain on the path forward. President Trump predicted that ''Obamacare will explode'' and offered no plan to stop it, but his was not the only voice from the White House.
The president ''wants to make sure that people don't get left behind'' in the search for affordable, quality health care, Reince Priebus, the White House chief of staff, said on ''Fox News Sunday.''
''I think it's time for our folks to come together,'' Mr. Priebus said, adding that it is time to ''potentially get a few moderate Democrats on board, as well'' as they try to bring down premiums and stabilize insurance markets.
That appeal was echoed by Senator Susan Collins of Maine, a moderate Republican who opposed the House Republicans' health bill and has also worked with Democrats to explore changes to the Affordable Care Act without repealing it.
''With the demise of the House bill, there's a real window of opportunity for a bipartisan approach to health care,'' she said.
In the wake of the Republican failure to make good on the seven-year-old promise to repeal the Affordable Care Act, Mr. Trump and congressional leaders find themselves at a political crossroads.
They could sabotage the Affordable Care Act's insurance markets, betting that Democrats would be blamed for collapsing coverage choices and spikes in insurance premiums and would then come to the negotiating table ready to toss the law and start fresh. Or they could work with Democratic lawmakers and moderate Republicans, who for years have discussed improvements to the Affordable Care Act, which, unlike many social welfare programs, has not been significantly updated or revised.
Speaker Paul D. Ryan has said he wants to move on to other issues, and indicated that Democrats would have to come to him if they want to cooperate on health care. After insisting that the health law had to be eradicated ''root and branch,'' Senator Mitch McConnell of Kentucky, the majority leader, has been remarkably quiet since Friday's debacle.
The messages from the White House, so far, have been mixed. ''You cannot fix a broken system,'' the White House budget director, Mick Mulvaney, said on NBC's ''Meet the Press.'' ''You are never going to fix that. This system must be removed.'' Mr. Trump appeared to endorse the crash-and-burn strategy on Saturday morning, saying on Twitter: ''ObamaCare will explode and we will all get together and piece together a great health care plan for THE PEOPLE. Do not worry!''
ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry! -- Donald J. Trump (@realDonaldTrump) March 25, 2017
But Mr. Priebus's softer vision gave some in Congress hope that a bipartisan approach could be found -- possibly to alleviate the health law's burdens on small business, repeal some of its more unpopular taxes, give employers more leeway on which employees they have to offer insurance to, and foster more competition among insurance companies. ''I believe that there is a group of centrist Democrats who recognize that the Affordable Care Act has flaws that must be fixed,'' Ms. Collins said. ''Until there was a repudiation of the House bill, they felt constrained from negotiating. Now that the House bill has died, I hope they will feel free to come to the table.''
Representative Don Young, Republican of Alaska, also called for bipartisanship. His state has benefited from its expansion of Medicaid under the health law, and would have been punished under the House Republican bill because its high premium costs would not have been offset by larger tax credits, as they are under current law.
''The reason why Obamacare failed was because it wasn't a bipartisan bill,'' Mr. Young said. Republicans, he said, made the same mistake, writing their bill without Democrats. ''We were very frankly guilty of that,'' he said.
Democrats also sounded more conciliatory.
''Until now, we haven't talked at all about compromise on the Affordable Care Act,'' said Representative Diana DeGette, Democrat of Colorado. ''From the moment it passed, Republicans started their mantra of 'repeal and replace.' Now that repeal seems to be off the table, I think it's in everybody's interest to make the law work better for our constituents.''
Representative Jim Cooper, a centrist Democrat from Tennessee who has often worked with Republicans, said: ''We need to fix the flaws in Obamacare. I hope Republicans are willing to do that, instead of just destroying Obamacare.'' But, he added, ''before we can work with them, the Republicans have to bargain in good faith and stop sabotaging Obamacare.''
Mr. Obama's health care law may not be imploding, as President Trump says. But in states as diverse as Alaska, Arizona, Minnesota, North Carolina and Pennsylvania, the public insurance marketplaces -- a central innovation of the Affordable Care Act -- are in trouble. Consumers have seen big premium increases for health plans sold by a shrinking number of insurers. ''People will have to come to the bargaining table sooner rather than later,'' said Chris Jacobs, a health policy analyst.
Within a few weeks, insurers must decide whether they will participate in the marketplaces in 2018. Insurance markets could quickly unravel if the House wins a court case challenging the legality of subsidies paid by the government to insurers on behalf of low-income people.
''The comments by President Trump and Speaker Ryan predicting the collapse of the A.C.A. and health insurance exchanges could become a self-fulfilling prophecy,'' said Kevin J. Counihan, who was the chief executive of the federal insurance marketplace, HealthCare.gov, under Mr. Obama.
Mr. Counihan said he saw a risk that some counties might not have any insurers on the exchange next year as major insurers like Aetna, Humana and UnitedHealth pull back from the program. Republicans in Congress, especially those from rural areas, share that concern. The Obama administration worked hard to keep insurers in the market, and to promote sign-ups during open enrollment season. Whether the Trump administration will do so is unclear.
Mr. Counihan suggested several areas where Republicans and Democrats in Congress could work together. They could, he said, give insurers more discretion to charge higher premiums for older adults, reflecting their medical costs. Under the Affordable Care Act, insurers can charge older adults no more than three times the rates for young adults. The House Republican bill would have allowed them to charge five times as much, or more if states wanted. A ceiling somewhere between those numbers might be appropriate, Mr. Counihan said.
In addition, he said, Congress could shorten the length of ''grace periods'' during which insurers must provide coverage to consumers who fail to pay their premiums. Lawmakers from both parties have also expressed a desire to give states more freedom to pursue their own ideas for expanding coverage, controlling health costs, reducing premiums and stabilizing insurance markets. Giving states more flexibility is consistent with Republicans' federalism philosophy. It also has potential appeal to Democrats because many states, including some with Republican governors, are to the left of the Trump administration on health policy.
One section of the Affordable Care Act, added at the behest of Senator Ron Wyden, Democrat of Oregon, already allows waivers for innovations in state health policy. But states say the requirements are so stringent that the waivers are of limited use.
''As Republicans, we know that one-size-fits-all works for no one and certainly did not work for the individual markets,'' said Representative Michael C. Burgess of Texas, the chairman of the Energy and Commerce subcommittee on health. Lawmakers of both parties also support legislation to help small businesses get insurance. As a possible model for bipartisan cooperation, they point to a bill signed by Mr. Obama in 2015 that changed the definition of ''small employer'' to protect such companies against increases in health insurance premiums.
The possibility of bipartisan cooperation may not last long. Some conservative Republicans like Senator Rand Paul of Kentucky and Representative Sean P. Duffy of Wisconsin said they would redouble their efforts to undo the Affordable Care Act. ''Rip it all out by the roots!'' Representative Steve King of Iowa said Friday in a Twitter post.
Now then bring to the House floor HR 175, the FULL ObamaCare repeal. Rip it ALL out by the roots! -- Steve King (@SteveKingIA) March 24, 2017
But other Republicans said that Democrats should be involved in efforts to rewrite the law. Representative Mark Sanford, Republican of South Carolina, opposed the House bill and said its demise could ''prove to be a catalyst'' for forging a consensus. ''Seeming stopping points can ultimately prove to be beginning points in life,'' he said.
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GRAPHIC: PHOTO: House Speaker Paul D. Ryan in Washington on Thursday. He has said he wanted to move on to other issues after the demise of the health care bill he pushed. (PHOTOGRAPH BY ERIC THAYER FOR THE NEW YORK TIMES)
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October 14, 2015 Wednesday
Late Edition - Final
Bush Offers Health Plan That Would Replace Much of the Affordable Care Act
BYLINE: By ROBERT PEAR and MATT FLEGENHEIMER; Robert Pear reported from Washington, and Matt Flegenheimer from New York.
SECTION: Section A; Column 0; National Desk; Pg. 17
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WASHINGTON -- Jeb Bush on Tuesday offered a detailed proposal to replace much of the Affordable Care Act with a more conservative health care plan that could lower individual insurance costs but would probably not protect as many people as President Obama's initiative.
''Innovations, not mandates, will bring down health care costs,'' Mr. Bush said at St. Anselm College in New Hampshire. ''If we're going to fix health care in this country, we need to wrest control away from Washington and give it back to the states, citizens and their care providers.''
Mr. Bush's plan would make good on Republicans' oft-stated pledge to repeal and replace Mr. Obama's signature domestic achievement, but it also points up the trade-offs that he and other Republican presidential candidates face. His reliance on low-cost catastrophic health plans could reduce premiums for some consumers, but could also leave them with fewer health benefits, and he would also loosen the Affordable Care Act's popular guarantee of coverage, regardless of a person's pre-existing medical conditions.
Mr. Bush would dismantle the elaborate structure of the health care law, offer income-tax credits for people to buy catastrophic coverage and offer states a sort of block grant to finance care for low-income people.
He would allow states to impose work requirements on able-bodied Medicaid beneficiaries, requirements that are opposed by the Obama administration but favored by some state officials.
Mr. Bush promised to work with states to develop a transition plan for 17 million people who are currently covered under the health law, or, as he put it, ''entangled in Obamacare.''
The president's health law was ''written by special interests, for the special interests,'' Mr. Bush said.
His proposals are consistent with priorities long favored by Republicans. He would give states more discretion over health care and more authority to regulate health insurance, rolling back many of the detailed federal standards set by the Affordable Care Act and in rules issued by the Obama administration.
Some of Mr. Bush's proposals could upset some people with employer-provided coverage. For example, he would limit the amount of tax-free health benefits that employees can receive from employers, capping the value at $12,000 a year for an individual and $30,000 for a family. Under current law, the value of employer-sponsored insurance is not counted or taxed as income for employees.
Mr. Bush said the proposed limits would ''encourage lower insurance premiums and higher wages.'' His proposal would replace an excise tax that the Affordable Care Act imposed on certain high-cost, employer-sponsored insurance plans. Mr. Bush said employers were arbitrarily reducing benefits to avoid this ''Cadillac tax,'' which is to take effect in 2018.
But the goal of his proposed cap on tax-free benefits appears to be similar. Many economists say the current tax-free treatment of employee health benefits tends to encourage the overuse of health care by insulating consumers from the true costs.
Gail R. Wilensky, who ran Medicare and Medicaid from 1990 to 1992 and is an informal adviser to the Bush campaign, said Mr. Bush's speech ''provided a lot of detail compared with what you normally see from candidates on the campaign trail.''
The White House declined to comment on Mr. Bush's proposals. The Democratic National Committee dismissed them as a catalog of lofty promises with no viable replacement for the 2010 law.
''His health care plan, like all of his other proposals, would help Jeb Bush and the wealthy like him while slashing and gutting a law that has insured over 17 million Americans and lowered the rise of health care costs,'' the committee said.
The Congressional Budget Office has said that similar proposals, offered by Republican lawmakers in the past five years, would not expand coverage as much as the Affordable Care Act. Gains in coverage in the past two years result, in part, from the law's expansion of Medicaid eligibility and from tax credits provided for the purchase of private insurance through new public marketplaces, health policy experts say.
In repealing the health law, Mr. Bush would eliminate the requirement for most Americans to carry health insurance and to pay tax penalties if they go without coverage.
Tax credits under the Bush plan appear to be less generous than those provided under the Affordable Care Act, but they would probably be available to more people. Mr. Bush's tax credits would be available regardless of a person's income and would be adjusted for age, with more assistance for older people.
Mr. Bush said the federal health law forced Americans to buy ''expensive products with benefits they do not want and may never need.'' He said that he would roll back the mandate for ''essential health benefits'' and give states discretion to allow lower-cost plans providing catastrophic coverage. Premiums could be lower as a result, he said.
In his proposal, Mr. Bush said, ''Obamacare created huge new subsidies for low-income Americans, but it left middle-income Americans facing higher premiums and higher out-of-pocket costs.''
He said he would ''give individuals without an offer of job-based coverage a tax credit, regardless of income, to help cover the cost of plans that provide preventive care and comprehensive protection for high-cost medical events.''
Also, Mr. Bush said, if employers cannot afford to provide insurance to workers, he would allow them to make tax-free contributions to the cost of health insurance purchased by employees on their own.
Federal law has long given a tax break to employers that provide coverage. But the Internal Revenue Service has ruled that the tax break is generally not available when employers reimburse employees for coverage that they buy themselves through the new insurance marketplaces, or exchanges.
Mr. Bush would also allow states to modify the current requirement for insurers to offer coverage to anyone who requests it. States could, for example, limit the guarantee so it would apply just to people who have been continuously insured, without a break in coverage.
Until states devise a workable alternative, Mr. Bush said, ''there will be a federal continuous coverage protection.'' In other words, he said, ''if an individual has maintained health insurance, they cannot be denied coverage when moving to a new state or changing insurance.''
Mitt Romney, the Republicans' 2012 presidential nominee, also proposed limiting the guaranteed coverage of pre-existing medical conditions to people who maintained consistent health insurance, arguing that it would prevent people from forgoing insurance until they got sick. The proposal proved to be a lightning rod in the 2012 campaign.
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The New York Times
April 11, 2017 Tuesday
Late Edition - Final
Administration Plans to Keep Paying Health Subsidies Disputed by House
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 1093 words
WASHINGTON -- The Trump administration says it is willing to continue paying subsidies to health insurance companies under the Affordable Care Act even though House Republicans say the payments are illegal because Congress never authorized them.
The statement sends a small but potentially significant signal to insurers, encouraging them to stay in the market.
The future of the payments has been in doubt because of a lawsuit filed in 2014 by House Republicans, who said the Obama administration was paying the subsidies illegally.
Without the subsidies, insurance markets could quickly unravel. Even more insurers could withdraw from the public marketplaces where more than 10 million Americans obtained coverage last year.
The Affordable Care Act requires insurers to reduce deductibles and other out-of-pocket costs for certain low-income consumers. The ''cost-sharing'' subsidies, which total $7 billion a year, compensate insurers for these discounts. Seven million people selecting marketplace plans for 2017 qualified for cost-sharing subsidies. They account for 58 percent of the people signing up for plans this year.
House Republicans sued the Obama administration, saying that the spending -- in the absence of an appropriations law -- was unconstitutional. A Federal District Court judge agreed and ordered a halt to the payments, but suspended her order to allow the government to appeal.
Democrats and consumer advocates say millions of people could lose coverage if the Trump White House reversed the position of the Obama administration, dropped the appeal and accepted the argument of House Republicans.
The Trump administration has not clearly indicated its position on the appeal. Asked to clarify, the Department of Health and Human Services sent a written statement on Monday: ''The precedent is that while the lawsuit is being litigated, the cost-sharing subsidies will be funded. It would be fair for you to report that there has been no policy change in the current administration.''
Its offer to continue paying subsidies could help stabilize insurance markets and provide some assurance to health plans that are deciding now whether to participate in 2018. But the lawsuit still hovers like a menacing cloud over the insurance marketplaces. Many insurers, having lost hundreds of millions of dollars on Affordable Care Act business, have withdrawn or announced plans to do so, creating concern that people in some counties might not have health plan options next year.
Because of the uncertainty about the future of the Affordable Care Act and of the subsidies, insurers say they will demand higher premiums to compensate for the risk if they stay in the market next year.
In their recent bill to repeal major provisions of the Affordable Care Act, House Republicans hoped to eliminate the cost-sharing subsidies. The bill collapsed on the House floor on March 24, torpedoed by the most conservative House members and by some moderate Republicans. The White House and Republican leaders say they hope to revive it.
Two influential Republicans -- Representatives Tom Cole of Oklahoma, the chairman of the Appropriations subcommittee responsible for health spending, and Greg Walden of Oregon, the chairman of the Energy and Commerce Committee -- said Congress should appropriate money for the cost-sharing subsidies.
''I don't think anybody wants to disrupt the markets more than they already are,'' Mr. Cole said in an interview. ''It's a very unstable market.''
Asked if he thought Congress should provide the money, Mr. Cole said, ''My personal opinion is yes.''
Likewise, Mr. Walden said last month, ''I will do everything I can to make sure that the cost-sharing reduction payments get made.'' That, he said, is ''an obligation we have not only to the insurers,'' but also to consumers, and ''we cannot leave them high and dry.''
Whether Republicans could muster the votes for a bill to provide the money or whether they would just muddle through, continuing the subsidy payments while courts decide the issue, is unclear.
Representative Chris Collins, Republican of New York, said members of the conservative House Freedom Caucus could block such a bill.
''Do you really think the Freedom Caucus would support a supplemental appropriation of $7 billion to continue supporting the insurance companies so they stay in and shore up Obamacare individual markets?'' Mr. Collins asked. ''Do you really think they're going to support that?''
''If Obama's appeal continues, then the payments continue,'' Mr. Collins added. ''But if President Trump or Attorney General Jeff Sessions were to decide not to continue the appeal, that's a game changer.''
The House Democratic whip, Steny H. Hoyer of Maryland, said Republicans would be to blame if consumers suddenly lost the cost-sharing subsidies. But Republican leaders may be reluctant to drop the lawsuit, which they filed to vindicate Congress's ''power of the purse.''
The subsidies at issue in the court case are different from the tax credits that help consumers pay monthly premiums. Congress clearly authorized payment of the tax credits, out of a government account earmarked for tax refunds. But Judge Rosemary M. Collyer of United States District Court in Washington found that Congress had not provided money for the cost-sharing subsidies.
The Obama administration, recognizing this oversight, asked Congress to provide the money. When Congress failed to do so, the Obama administration decided that it did not need a separate appropriation to reimburse insurers.
Judge Collyer said that making the payments without an appropriation ''violates the Constitution.''
Mr. Cole said he believed that the Trump administration and House Republicans could probably ''find common ground'' to continue the cost-sharing payments at least temporarily. But a settlement of the court case would not wipe out Judge Collyer's decision that the House had a right to pursue its claims in court.
The Supreme Court has held that the losing party in a lawsuit cannot automatically wipe out an unfavorable court decision by settling the case after filing an appeal.
The Justice Department has strong institutional reasons for not wanting Judge Collyer's decision to stand as precedent. Courts, it said, should not ''open the floodgates'' to lawsuits by Congress in what are essentially political disputes between the legislative and executive branches of the government.
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URL: http://www.nytimes.com/2017/04/10/us/politics/affordable-care-act-trump-subsidies.html
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The New York Times
January 12, 2017 Thursday 00:00 EST
House Expected to Follow Senate's Lead on Rush to Repeal Health Law
BYLINE: THOMAS KAPLAN, ROBERT PEAR and EMMARIE HUETTEMAN
SECTION: US; politics
LENGTH: 1558 words
HIGHLIGHT: A House vote on Friday will come after the Senate approved a measure that would allow Republicans to speedily gut the Affordable Care Act with no threat of a filibuster.
WASHINGTON - The House is expected to give final approval on Friday to a measure that would allow Republicans to speedily gut the Affordable Care Act with no threat of a Senate filibuster, a move that would thrust the question of what health law would come next front and center even before President-elect Donald J. Trump takes office.
The House vote would come after the Senate narrowly approved the same measure, a budget blueprint, early Thursday morning. Americans woke up Thursday to the realization that a Republican Congress was serious about repealing President Obama's signature domestic achievement - a move that could leave 20 million Americans unsure of their health coverage and millions more wondering if protections offered by the Affordable Care Act could soon be taken away.
"This is a critical step forward, the first step toward bringing relief from this failed law," Senator Mitch McConnell of Kentucky, the majority leader, said.
Democrats said the rush to repeal was the height of legislative irresponsibility and would endanger the health of millions.
"For the life of me, I can't understand the need to take health care away from people, and why in the world anybody would even contemplate doing that without something to replace it," said Representative Louise M. Slaughter of New York. "Just snatching it out from under them and it's gone. I think that there's going to be a mighty rumble in this country, an outburst of anger and fear."
What comes next may be the most pressing problem facing Republicans, who may find that dismantling the health law is far easier than replacing it with one that can unite their fractious members - and win over some Democrats.
After a marathon session, the Senate voted 51 to 48 to approve a budget measure that would clear the way for the health care law to be repealed with a simple Senate majority. As the House approached its vote, some Republicans remained reluctant to act without a clear strategy to replace the health law.
"We'd like to see a little more flesh on the bone before we sign on the dotted line," said Representative Andy Harris of Maryland, an anesthesiologist and a member of the conservative House Freedom Caucus.
Republicans skeptical of moving forward risked looking hostile to the repeal effort. And there was a prevailing sense of the importance of following through on a campaign promise upon which so many House Republicans had staked their political reputations.
"This is an issue that really and truly, in some ways, put two-thirds of our conference here," said Representative Doug Collins of Georgia, a member of the party's leadership team.
"Everybody wants to get it right," he said.
Republican leaders sought to reassure members that the House budget vote - procedurally important as it is - is only the first step in an exhaustive process to repeal and replace the Affordable Care Act. Four committees in the House and Senate would then be tasked with drafting the legislation that would gut the existing health law.
The concerns fostered a remarkable alignment between some centrist Republicans and their counterparts in the House Freedom Caucus, the hard-right group that is disposed to disagree with its own party's leaders.
Speaker Paul D. Ryan of Wisconsin worked to soothe concerns even as he expressed the urgent need to get rid of a law that Republicans hate. Republicans would embark on "a thoughtful, step-by-step process," he said, even though the law is "collapsing while we speak."
Mr. Ryan also said he was working with Mr. Trump and Vice President-elect Mike Pence. Mr. Trump called this week for a near simultaneous repeal and replacement of the Affordable Care Act.
"We are in complete sync," Mr. Ryan said.
But Republicans face a significant challenge in passing the necessary legislation to replace the health care law. They can repeal major parts of the existing law without facing a filibuster, but they would not be able put in place a full replacement in the same measure, because arcane budget rules limit what can be included in such a filibuster-proof bill.
Instead, they would almost certainly need to pass another bill or multiple bills with 60 Senate votes, and that would require at least some Democratic cooperation.
Senator Joe Manchin III, Democrat of West Virginia, a prime target for Republican wooing, asserted on Thursday that Mr. Trump did not want to "repeal" Obamacare but "repair" it. He cited Mr. Trump's stated support for popular provisions like requiring insurers to provide coverage for people with pre-existing medical conditions.
"We're in a repair mode," Mr. Manchin said. "They need 60 votes to repair. I'm actually happy to work with them."
Republicans in Congress have offered many replacement ideas, but it is not clear whether their most conservative members will ever be able to agree on legislation acceptable to the party's moderates.
A manifesto issued by House Republicans in June outlined a consensus proposal, produced by the chairmen of four House committees, including Representative Tom Price of Georgia, chosen by Mr. Trump to be secretary of health and human services.
Mr. Trump and congressional leaders said they were counting on Mr. Price to help them write a replacement for the Affordable Care Act, most likely drawing from a bill that he introduced in July 2009 and has reintroduced several times since.
"I think there's an acknowledgment both by the administration coming in and people around here that his imprint needs to be on this," Senator Bob Corker, Republican of Tennessee, said.
Senate Republicans do not have a detailed plan. But Senator Lamar Alexander of Tennessee, chairman of the health committee, laid out a road map on the Senate floor this week that pointed to a measure potentially more expansive than House plans.
The major Republican proposals have not been analyzed by the Congressional Budget Office, so no independent or authoritative estimates exist of their costs or the number of people who might gain or lose coverage.
On several points, the major Republican proposals agree.
They would eliminate the requirements that most Americans carry health insurance and that larger employers offer it to employees.
They would offer tax credits for health insurance and new tax incentives for health savings accounts; provide subsidies for state high-risk pools, to help people who could not otherwise obtain insurance; and make it easier for insurance companies to sell policies across state lines.
They would also provide some protection for people with pre-existing conditions who have maintained "continuous coverage." They could not be dropped by an insurer and could move from one plan to another, but a person with a pre-existing condition seeking insurance after a lapse of coverage could in some cases be charged higher rates. The protections would be weaker than those in the Affordable Care Act.
Republicans also do not agree on how to pay for a replacement plan. In the House document, Republicans proposed limiting the value of tax-free health benefits that employers could provide to employees.
Under the current law, employees do not have to pay federal income tax on contributions that employers make to their health insurance. House Republicans said this open-ended subsidy had encouraged people to select more expensive coverage, driving up premiums.
But business groups, labor unions and some conservative lawmakers vehemently oppose that change, saying it amounts to a new tax on benefits and on working families. Senate Republicans have also not expressed support for the idea.
Many House Republicans, including Mr. Price, would provide tax credits to help people buy insurance. But the amount of assistance would increase with age and would not be tied to income, as it is under the existing health care law.
The subsidies would probably be smaller than under the Affordable Care Act. But insurance would be less expensive, Republicans say, because the government would impose fewer requirements.
Mr. Alexander said he would "allow individuals to use their Obamacare subsidies to purchase state-approved insurance outside the Obamacare exchanges." Under the health care law, such assistance can be used only in the insurance exchanges.
Many Republicans say states should have much more power to define "essential health benefits."
On Medicaid, the federal insurance program for low-income people, House Republicans would roll back the Affordable Care Act's expansion and give each state a fixed amount of money for each beneficiary - or a lump sum of federal money for all of a state's Medicaid program.
But more than half the states, including some with Republican governors, have expanded Medicaid eligibility under Mr. Obama's law, with large sums of federal money, and pragmatic Republicans are reluctant to snatch away the federal money that has allowed big increases in Medicaid enrollment.
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PHOTO: Senator Mitch McConnell said a Senate vote on Thursday was "the first step toward bringing relief" from the Affordable Care Act. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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November 8, 2015 Sunday
Late Edition - Final
Affordable, but Not That Egalitarian
BYLINE: By TYLER COWEN.
Tyler Cowen is a professor of economics at George Mason University. Follow him on Twitter at @tylercowen.
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The Affordable Care Act has generated an enormous amount of partisan rancor, but with more access to data, it is worth taking stock of how it has actually been working.
We can safely say that the policy is costing less than anticipated, perhaps 20 percent less, according to a Congressional Budget Office estimate, and that it has reduced the number of Americans without insurance. But the numbers also suggest that by some measures, the Affordable Care Act has had only a limited impact on economic inequality. In fact, I view the policy as an object lesson in the complexity of reducing the harmful consequences of inequality in the United States.
The act has many parts, but let's focus on the mandate, a core feature that requires those without insurance to buy it. It was intended to help millions of Americans who did not have health care coverage. Under the program, government subsidies are available for the needy, and there is clear evidence that the poorest people, who receive the largest subsidies, are better off under the health reform law.
In that sense, the program has been a success. But whether other individuals subject to the insurance mandate -- those who qualify for lower subsidies or for none at all -- are also better off is much harder to say, some recent research has found.
Of course, this question may seem simple if you consider health care coverage to be an essential component of a good human life, and perhaps of social justice as well. If you begin with those assumptions, you might conclude that when you require people to buy insurance coverage you are improving their lives -- even if they are not willing to pay for the insurance without prompting from the government.
But there is another way of looking at it, one used in traditional economics, which focuses on how much people are willing to pay as an indication of their real preferences. Using this measure, if everyone covered by the insurance mandate were to buy health insurance as the law dictated, more than half of them would be worse off.
This may seem startling. But in an economic study, researchers measured such preferences by looking at data known as market demand curves. Practically speaking, these demand curves implied that individuals would rather take some risk with their health -- and spend their money on other things -- partly because they knew that even without insurance they still would receive some health care. These were the findings of a provocative National Bureau of Economic Research working paper, ''The Price of Responsibility: The Impact of Health Reform on Non-Poor Uninsureds'' by Mark Pauly, Adam Leive, and Scott Harrington; the authors are at the Wharton School at the University of Pennsylvania.
One implication is that the preferences of many people subject to the insurance mandate are likely to become more negative in the months ahead. For those without subsidies, federal officials estimate, the cost of insurance policies is likely to increase by an average of another 7.5 percent; even more in states like Oklahoma and Mississippi. The individuals who are likely losers from the mandate have incomes 250 percent or more above the federal poverty level ($11,770 for a single person, more for larger families), the paper said. They are by no means the poorest Americans, but many of them are not wealthy, either. So the Affordable Care Act may not be as egalitarian as it might look initially, once we take this perspective into account.
It is a matter of philosophy whether we should help people even if they may not want to bear the costs, or instead should honor their individual preferences, but either way there is a sustainability problem. Consider that the health law was enacted to replace an unsustainable system in which uninsured people relied on last-ditch emergency room care. Yet enrollment projections suggest that the Affordable Care Act's insurance mandate may face sustainability issues of its own. Recently the Obama administration announced that it expected 2016 enrollments through insurance exchanges of about 10 million people, whereas a 2013 Congressional Budget Office estimate projected enrollments of about 22 million; that is partly why the expected costs of the program have fallen. Nine million Americans gained insurance coverage last year, in large part because of the Affordable Care Act, but the smaller-than-expected figures for exchange enrollment mean there may not be enough healthy people to subsidize the overall risk pool without insurance prices rising even more.
Then there is the separate problem of resistance to the expansion of Medicaid, which provides assistance to many of the neediest people but is voluntary for individual states as a result of the Supreme Court's Affordable Care Act ruling of 2012. As a political matter, expanding coverage for the uninsured through Medicaid remains contentious, with many states still refusing to go along.
In short, while numerous government programs redistributed income toward the poor successfully in the past, successive improvements, as exemplified by the Affordable Care Act, have become harder to accomplish, as many of the easiest and most efficient opportunities have already been exploited. We have ended up at margins where political divisions and interest group capture make further progress harder to carry out, no matter how good the proposed policies may seem on the drawing board. While politicians wrangle over the health care law, many of the monetary gains from the changes in the system are benefiting the health care establishment rather than the patients.
The Affordable Care Act does not seem to be wildly popular, but it is also striking that it has been receiving relatively few direct attacks during the Republican presidential debates. If nothing else, this all may be a sign that the age of America's grand ambitions is over.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
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August 28, 2014 Thursday
Is 'Obamacare' No Longer a Big Deal?
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 247 words
HIGHLIGHT: It looks as though Republicans are no longer betting on the Affordable Care Act as a surefire political weapon.
It looks as though Republicans are no longer betting on the Affordable Care Act as a surefire political weapon. The Upshot reported on Wednesday that, in the summer of 2013, lawmakers churned out 530 news releases using the term "Obamacare." So far this summer, in advance of the mid-terms when one might expect that number to go up, it's fallen dramatically, to 138 so far.
In addition to this sign of waning interest, Bloomberg reported last Tuesday that Republicans in competitive Senate races "are easing off their strategy of criticizing Democrats over the Affordable Care Act."
Here's the situation in North Carolina, according to Bloomberg, where Democratic Senator Kay Hagan is in a statistical tie with her Republican challenger, Thom Tillis:
In April, anti-Obamacare advertising dwarfed all other spots in North Carolina. It accounted for 3,061, or 54 percent, of the 5,704 top five issue ads in North Carolina, according to Kantar Media's Campaign Media Analysis Group. By July, the numbers had reversed, with anti-Obamacare ads accounting for 971, or 27 percent, of the top issue ads, and the budget, government spending, jobs and unemployment accounting for 2,608, or 72 percent, of such ads, CMAG data show.
Republicans of course haven't embraced the Affordable Care Act. Now that it's actually gone into effect, though, they seem to be slowly coming around the reality that it's not at all the disaster they assumed it would be, and therefore may not draw voters to the polls.
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November 7, 2014 Friday
Late Edition - Final
A Post-Election Day Certainty: New Scrutiny for the Affordable Care Act
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1120 words
WASHINGTON -- This week's elections ensure a new round of political attacks on the Affordable Care Act, but they also create potential opportunities to repair provisions of the law that people on both sides of the partisan divide would like to fix.
With the shift in power in the Senate, Republicans can turn up the heat on the White House, which has dismissed as political stunts repeated House votes to repeal the law.
Republican leadership aides in the Senate and the House said that a few more such votes were likely because many of the new Republican lawmakers had vowed in their campaigns to dismantle the Affordable Care Act. President Obama said Wednesday that he would oppose changes that ''undermine the structure of the law'' or ''take away health care from the 10 million people who now have it and the millions more who are eligible to get it.''
But Mr. Obama said he would be ''open and receptive'' if Republicans proposed ''responsible changes to the Affordable Care Act to make it work better.''
Republicans are sure to test that commitment, knowing that their idea of ''responsible changes'' can appear to Democrats like an attempt to gut the law.
''In the new Congress, there will be at least one vote on full repeal of the Affordable Care Act,'' said Joseph R. Antos, an economist at the American Enterprise Institute, a right-of-center think tank. ''New members ran on that as part of their platform. Beyond that, the likely strategy is to pursue targeted proposals that on their face make sense to the public at large.''
Mr. Antos pointed to provisions of the law that define employers' responsibility to provide insurance to employees. Under the law, larger employers are subject to tax penalties if they do not offer coverage to ''full-time employees,'' defined as those who work at least 30 hours a week, on average. Senators Susan Collins of Maine, a Republican, and Joe Donnelly of Indiana, a Democrat, have introduced a bill to change that to 40 hours, and the House in April passed similar legislation.
Mr. Obama threatened to veto the bill last spring, saying it would increase the number of uninsured. On the other hand, some public and private employers say they have reduced the work hours of some employees to avoid the expense of providing them with health insurance, and if the Senate joins the House in pushing such changes, Mr. Obama would be hard-pressed to avoid negotiations.
Senator Mitch McConnell of Kentucky, the Republican in line to be majority leader, and Speaker John A. Boehner said they would advance a proposal to restore what they called ''the traditional 40-hour definition of full-time employment.''
Short of repealing the whole law, Republicans list other changes they may seek: repealing a federal excise tax on medical devices; eliminating an independent board that is supposed to limit the growth of Medicare spending; and abolishing special payments to insurers that Republicans criticize as a bailout for the industry.
Mr. Boehner made the case for piecemeal changes on Thursday. ''Just because we may not be able to get everything we want, doesn't mean that we shouldn't try to get what we can,'' he said.
Whether the administration is willing to negotiate is unclear. Even if the president authorized negotiations, Senate Republicans would still need 60 votes in most cases, and they say they doubt that Mr. Obama could deliver the votes of Democrats needed to achieve such a majority.
White House officials have repeatedly complained that Republican hostility to the health care law made it impossible to pass ''technical corrections'' or other legislation to clarify or modify its provisions. Supporters of the law would, for example, like to clarify that premium subsidies are available to people in all states, regardless of whether they have an insurance exchange established by the state or by the federal government. The administration and its critics are locked in court fights over that question, which arises from ambiguous language in the law.
The power shift in Washington comes just as some supporters of the Affordable Care Act are raising questions about its requirement for employers to offer coverage to employees.
Dropping that requirement would not significantly affect the number of Americans with coverage, researchers at the Urban Institute said in a recent report titled, ''Why Not Just Eliminate the Employer Mandate?''
Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, supports the Affordable Care Act but said the employer mandate ''cries out for repair.''
Mr. Obama said Wednesday that he could not accept repeal of the individual mandate. But he did not make such a statement about enforcement of the employer mandate, which he has twice delayed.
In an interview Thursday, Representative Michael C. Burgess, Republican of Texas and chairman of the Congressional Health Care Caucus, said, ''I would be surprised if the president vetoed repeal of the employer mandate.''
Mr. Obama had been hoping that the elections would increase the number of Democratic governors eager to expand Medicaid eligibility, and to that end, he campaigned last week for Democratic candidates in Wisconsin and Maine. But in both states, voters re-elected Republican governors opposed to expansion of the program.
The election results do not immediately alter the outlook for expansion of Medicaid, but could strengthen the hand of Republican governors negotiating with the Obama administration for permission to expand it in their own way. Gov. Gary R. Herbert of Utah and Gov. Mike Pence of Indiana, both Republicans, have been engaged in such negotiations for months.
Speaking to state Medicaid directors on Tuesday, Sylvia Mathews Burwell, the secretary of health and human services, said the administration was eager to cut deals. ''We're eager and willing to work with states that have yet to expand,'' Ms. Burwell said.
Sara Rosenbaum, a professor of health law and policy at George Washington University, said some states that have refused to expand Medicaid might go along with a partial expansion -- an option that is not allowed by the administration but could be considered by Congress.
Under the law, the federal government offers large financial incentives to states that agree to provide Medicaid to anyone with income less than 138 percent of the poverty level (less than $16,105 a year for an individual). Among states that have chosen not to expand Medicaid, some want to extend eligibility up to the poverty level ($11,670 for an individual), but no further.
''This is a request that states have repeatedly made to the administration,'' Ms. Rosenbaum said. ''They may find that a Republican Congress is more receptive to the idea.''
URL: http://www.nytimes.com/2014/11/07/us/politics/a-post-election-day-certainty-new-scrutiny-for-the-affordable-care-act.html
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August 18, 2015 Tuesday
Scott Walker's Health Care Plan Relies on Tax Credits to Buy Coverage
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 730 words
HIGHLIGHT: Gov. Scott Walker’s health care plan makes a full repeal of Obamacare his top priority, then proposes a system of tax credits that would allow Americans who do not get health insurance through their employers to buy individual plans.
"Repeal and replace" has been a mantra for Republicans when discussing President Obama's health law. On Tuesday, Gov. Scott Walker, the Republican presidential candidate from Wisconsin, offered some details on how he would replace the Affordable Care Act if he is elected.
Mr. Walker's plan makes a full repeal of the law his top priority, then proposes a system of tax credits that would allow Americans who do not get health insurance through their employers to purchase individual plans. The credits would be based on age and consumers could then decide what plan to purchase, if they opt to buy health insurance at all.
"My plan fully repeals Obamacare and replaces it with a system that puts patients and families back in charge of their health care," Mr. Walker saysin an outline of his plan.
Repealing the Affordable Care Act has been a rallying cry for Republicans since it was enacted without their support in 2010. Mr. Walker's detailed critique of the law and his plan to replace it by lowering taxes and offering consumers more freedom comes as he has been struggling in recent polls after a tepid debate performance.
Despite continuing resistance to the law, dismantling it would likely be a big challenge for a Republican president. The Obama administration said this month that the number of people without health insurance continues to decline, and has dropped by 15.8 million, or a third, since 2013. Meanwhile, studies have shown that the law has helped to keep insurance premiums in check.
"If this vague grab-bag of conservative wish-list items is the best health plan the G.O.P. can come up with for the largest economy on earth, it's the clearest signal yet that Republicans like Scott Walker are out of ideas and out of touch," said Eric Walker, a spokesman for the Democratic National Committee.
Senator Marco Rubio shed some light on his own health care reform policy this week. The Republican from Florida would also promote tax credits as a method of making insurance affordable and create federally backed "high risk pools" in states so that the sick can buy insurance at reasonable prices.
In Wisconsin, Mr. Walker has been a staunch opponent of the Affordable Care Act and has resisted taking federal funds to expand Medicaid in the state. A report last year faulted Mr. Walker for costing Wisconsin $500 million in lost savings because of his opposition to the law, but the governor maintained that such reliance on federal money would have been a mistake.
"We believe confidently going forward this federal government is likely to renege from its promises on Medicaid to the states," he said last summer. "And we won't be exposed to that."
Mr. Walker vows to do away with the Affordable Care Act's requirement that Americans purchase health insurance. Instead, his plan would seek to limit insurance premiums by opening the market so that consumers can shop for plans across state lines, thus intensifying competition among insurance companies.
The proposal also calls for reforms to Medicaid and improvements to health savings accounts that would give patients more pretax money to pay their health bills.
Mr. Walker also tries to address the issue of covering people with pre-existing conditions, which was one of the most important reforms in the Affordable Care Act because of the prohibitive prices sick people often faced when trying to purchase health plans. He promises "additional reforms to insurance coverage laws" that would prevent companies from discriminating against people who find themselves ill and without health insurance. Federal funds would be distributed to the states to help people with these conditions buy coverage.
Many of Mr. Walker's proposals on overhauling the health care system have been mainstays for Republicans over the years, and his plan offers little insight into how its costs or impact on the economy would compare with Obamacare. But pointing to the success of Wisconsin's BadgerCare program for the poor, Mr. Walker said he is confident that a similar structure could work across the United States.
"My plan would roll back the damage done by Obamacare and when compared to the realities that existed before Obamacare, would not add to the deficit," he said.
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February 17, 2017 Friday
Late Edition - Final
House G.O.P. Leaders Outline Plan to Replace Health Act
BYLINE: By ROBERT PEAR and THOMAS KAPLAN; Emmarie Huetteman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 1275 words
WASHINGTON -- House Republican leaders on Thursday presented their rank-and-file members with the outlines of their plan to replace the Affordable Care Act, leaning heavily on tax credits to finance individual insurance purchases and sharply reducing federal payments to the 31 states that have expanded Medicaid eligibility.
Speaker Paul D. Ryan and two House committee chairmen stood with the new secretary of health and human services, former Representative Tom Price of Georgia, preparing Republican lawmakers for a weeklong Presidents' Day recess that promises to be dominated by angry or anxious questions about the fate of the health law.
But the talking points they provided did not say how the legislation would be paid for, essentially laying out the benefits without the more controversial costs.
It also included no estimates of the number of people who would gain or lose insurance under the plan, nor did it include comparisons with the Affordable Care Act, which has extended coverage to some 20 million people.
With the House proposal's rollback of Medicaid payments to the states, it appears probably that the number covered would be smaller.
House Republican leaders asserted in a document describing their plan that they would not ''pull the rug out from anyone who received care under states' Medicaid expansions.''
But Kenneth E. Raske, the president of the Greater New York Hospital Association, expressed alarm, saying the proposals would ''put a huge amount of pressure on state budgets and put many Americans at risk of losing health care coverage.''
Sketchy as the outline was, it envisions major changes.
It would fundamentally remake Medicaid, a Great Society program that provides health care to more than 70 million Americans, not just the poor, but also middle-class people who have run out of money and need nursing home care. Under the plan, Medicaid, an open-ended entitlement program designed to cover all health care needs, would be put on a budget.
The Affordable Care Act's subsidies, which expand as incomes decline, giving the poorer people more help, would be replaced by fixed tax credits to help people purchase insurance policies. The tax credits would increase with a person's age, but would not vary with a person's income.
And new incentives for consumers to establish savings accounts to pay medical expenses still assume that workers would have money at the end of a pay period to sock away.
The House Republican plan would also make it easier for consumers to buy health insurance from companies licensed in other states, an idea long promoted by Republicans in Congress and championed by President Trump in his campaign last year.
After the recess, Mr. Ryan said: ''We intend to introduce legislation to repeal and replace Obamacare. It has become increasingly clear that this law is collapsing. People's premiums are getting higher and higher. Their deductibles are soaring, and their choices are dwindling.''
Mr. Price told House Republicans that Mr. Trump ''is all in on this.''
Mr. Ryan's presentation on Thursday was meant to generate a sense of momentum for the Republicans' campaign to eviscerate President Barack Obama's health care law -- a campaign that has been plagued by apprehensions, doubts and divisions among Republicans in the last few weeks.
It was not clear whether the plan as outlined would get Republicans much closer to resolution. Senator Lamar Alexander of Tennessee, chairman of the Senate health committee, said that he and other Senate committee chairmen were working with their House counterparts, with the goal of developing a ''consensus document.'' The House, he said, will probably act first but ''will have the input of senators and the president.''
House conservatives are saying that any plan must begin with a full repeal of the Affordable Care Act and a replacement that looks nothing like it. Representative Mark Meadows, Republican of North Carolina and the chairman of the hard-line Freedom Caucus, said Republicans needed to talk about replacement measures ''in specific terms, not in aspirational terms.''
''We believe that it's time that we make some very difficult decisions and move forward,'' Mr. Meadows said.
Any plan that can satisfy House conservatives would face great uncertainty in the more moderate Senate.
The plan unveiled on Thursday by House Republican leaders would make huge changes in Medicaid. It would eventually undo the Affordable Care Act's expansion of Medicaid and give each state a fixed amount of money for each beneficiary. As an alternative, they said, a state could receive a lump sum of federal money for all of its Medicaid program, or a block grant.
In either case, the federal government would gradually reduce the extra payments it makes to states that have expanded Medicaid under the 2010 health care law. States could continue providing Medicaid to the newly eligible beneficiaries, but the federal share of the costs would decline to the regular federal share of Medicaid costs for other beneficiaries.
The federal government now pays more than 90 percent of the costs for newly eligible beneficiaries in states that expanded Medicaid. Under the House Republican plan, the federal share would decline to 50 percent in states like New York, New Jersey, Connecticut and California, resulting in a significant loss of federal revenue.
In a number of states that have expanded Medicaid, Republican governors and Republican members of Congress have made clear that they do not like the idea of a block grant or a per-beneficiary allotment.
The Congressional Budget Office says that 12 million people have insurance because they became eligible for Medicaid under the Affordable Care Act, and it estimates that federal spending for this group will be $70 billion this year.
The House Republican plan would immediately eliminate tax penalties for people who do not have insurance and employers that do not offer it.
It would also eliminate taxes and fees that help pay for the expansion of coverage under the 2010 health care law. These include fees collected from health insurance companies and manufacturers of brand-name prescription drugs and an excise tax on makers of medical devices.
House Republicans have repeatedly said that they would continue providing some protection for people with pre-existing medical conditions. But the document describing their proposal does not say how they would do that.
Mr. Ryan said the tax credits envisioned by House Republicans were different from those provided in the Affordable Care Act.
Under that law, the tax credits are available only for insurance products that meet detailed federal standards and are purchased through an insurance exchange like HealthCare.gov.
By contrast, Mr. Ryan said, with the Republican version of tax credits, people can ''buy the health insurance plan of their choosing,'' which could cost less and have less generous coverage than the plans now available.
''You get the freedom to do what you want and buy what you need,'' Mr. Ryan said.
During a transition period, House Republicans would continue ''Obamacare subsidies,'' but they would provide a little more assistance to young people and a little less to older Americans.
The House Republican plan would provide an unspecified amount of money for ''innovation grants,'' which states could use to help defray consumers' out-of-pocket costs or to establish ''high-risk pools'' for people with serious chronic conditions.
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URL: http://www.nytimes.com/2017/02/16/us/politics/affordable-care-act-congress.html
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January 30, 2016 Saturday
Hillary Clinton Criticizes Bernie Sanders and Ted Cruz on Healthcare
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 354 words
HIGHLIGHT: Hillary Clinton staked out her position as the lone defender of the Affordable Care Act on Saturday night, warning that her Democratic rival, Senator Bernie Sanders, would scrap it and start over and that Republicans would hand healthcare back to insurers and drug-makers.
CEDAR RAPIDS, Iowa - Making her final push before the Iowa caucuses, Hillary Clinton staked out her position as the lone defender of the Affordable Care Act on Saturday night, warning that her Democratic rival, Senator Bernie Sanders, would scrap it and start over and that Republicans would hand healthcare back to insurers and drug-makers.
While she tends to lump Republicans with Donald J. Trump these days, Mrs. Clinton made clear that she is also paying attention to Senator Ted Cruz.
The Texas senator found himself in an awkward position on Saturday afternoon when a supporter of Mrs. Clinton confronted him at a rally about his plan to repeal the Affordable Care Act.
The man told a painful story of how his brother-in-law was unable to get insurance before the law was passed and that when he finally could finally see a doctor, he learned that he was a riddled with cancer. After briefly expressing condolences, Mr. Cruz went on to assail the law.
The exchange caught Mrs. Clinton's attention.
At a rally in a high school gymnasium where she was joined by her husband and daughter, Mrs. Clinton brought up the story as an example of why it would be dangerous to elect a Republican such as Mr. Cruz as president.
"Cruz went off on one of his ideological, critical comments about the Affordable Care Act," Mrs. Clinton said after recounting the confrontation. "He never says what the alternative would be."
Mrs. Clinton went on to say that Mr. Cruz and his Republican colleagues have no plan for replacing President Obama's signature piece of legislation because they intend to leave health care in the hands of big companies.
"That's fine for them," she said. "It's not fine for me."
The future of the Affordable Care Act has been a hot subject for both Democrats and Republicans, as Mr. Sanders wants to replace the law with a government-run Medicare-for-all program. Mrs. Clinton has argued that while she, too, wants all Americans to be insured, Mr. Sanders's plan could not pass. Re-igniting such a debate, she predicts, would be wrenching for the country.
"We can't repeal it and we can't start over," Mrs. Clinton said.
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March 9, 2017 Thursday
Late Edition - Final
Health Groups Unite to Oppose Republican Bill
BYLINE: By ABBY GOODNOUGH, ROBERT PEAR and THOMAS KAPLAN; Jennifer Steinhauer, Emmarie Huetteman and Jeremy W. Peters contributed reporting from Washington, and Reed Abelson from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1527 words
WASHINGTON -- Influential groups representing hospitals and nurses came out on Wednesday against a Republican bill to repeal and replace the Affordable Care Act, joining doctors and the retirees' lobby to warn that it would lead to a rise in the uninsured.
In a letter to lawmakers, major hospital groups wrote, ''As organizations that take care of every individual who walks through our doors, both due to our mission and our obligations under federal law, we are committed to ensuring health care coverage is available and affordable for all.''
The groups, including the American Hospital Association, the Association of American Medical Colleges, the Catholic Health Association of the United States and the Children's Hospital Association, said they could not support the bill ''as currently written.''
The hospitals and the American Nurses Association joined the American Medical Association and AARP, which rejected the bill on Tuesday.
House Republicans have been left scrambling to marshal support from businesses and other interests that stand to benefit from lower taxes if the bill passes. Insurers are on the fence, and other powerful forces like pharmaceutical companies remain largely on the sidelines.
Squeezed between wary health care providers and angry conservatives who believe that the bill leaves too much of the Affordable Care Act in place, the Republican leadership and President Trump appear to be facing an uphill climb.
But the White House appears increasingly confident about the prospects for a health care overhaul to pass in the House. In a meeting with conservative leaders in the Oval Office on Wednesday, Mr. Trump said he anticipated the most trouble in the Senate, where moderate and conservative lawmakers are opposing the plan for different reasons. He said he was prepared to pressure holdout senators by holding the kind of stadium-style rallies he led during his presidential campaign.
The House speaker, Paul D. Ryan, said Republicans were ''going through the inevitable growing pains of being an opposition party to becoming a governing party.''
''It's a new system for people,'' he added. ''But it's all the more reason why we have to do what we said we would do and deliver for the American people, and govern and use our principles.''
The array of groups taking strong positions against the bill is evidence that its potential consequences extend far beyond health insurance coverage, to much of the nation's economy.
The opposition is also a powerful reminder of how many past efforts to overhaul the American health care system failed because of resistance by major interest groups. Winning the support of the health care and insurance industries allowed the Obama administration in 2010 to push through the most significant health care legislation since President Lyndon B. Johnson's Great Society.
Within a few months after President Barack Obama took office in 2009, his administration had lined up support from health care providers, insurers, consumers and pharmaceutical makers by offering a grand bargain: The health bill would include a requirement that most Americans have health insurance, providing millions of new customers through the law's often substantial premium subsidies and its option for states to expand Medicaid. In exchange, hospitals would have to accept spending cuts and the health care industry would have to accept new taxes to pay for the legislation.
The Obama White House dedicated enormous effort to win pledges of support before Democrats even put out a bill -- an effort not replicated by the Trump White House or Republican leaders in Congress.
But the Affordable Care Act also created an array of taxes that the Republicans now hope to wipe away, helping them win the support of groups like the U.S. Chamber of Commerce and Americans for Tax Reform, led by the anti-tax activist Grover Norquist.
The congressional Joint Committee on Taxation issued estimates this week showing how much revenue the government could lose starting in 2018 under the Republican bill, which the party has called the American Health Care Act, as a result of repealing taxes on drug makers (nearly $25 billion over 10 years), insurers (nearly $145 billion), makers of medical devices (nearly $20 billion), and high-income households (more than $270 billion from taxes on earned income and investment income).
''The American Health Care Act repeals the medical device tax, which will result in greater investments in medical cures, lower health care costs and more high-tech manufacturing jobs in communities across the United States,'' trumpeted the Medical Device Manufacturers Association.
The extent to which these groups mobilize on behalf of the Republican bill may help determine whether it succeeds.
For now, the supporters of the House bill seem badly outgunned by opponents. On Wednesday, as two congressional committees took up the Republican repeal-and-replace bill, the American Nurses Association and a coalition of hospital groups came out against the proposal.
The A.M.A., which has nearly 235,000 members and calls itself the voice of the medical profession, sent a letter to leaders of the two committees on Tuesday saying it could not support the Republican bill ''because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.''
In particular, the group said it opposed a plan to replace the sliding, income-based premium tax credits provided under the Affordable Care Act with fixed credits based on age. The current system, it said, ''provides the greatest chance that those of the least means are able to purchase coverage.''
America's Health Insurance Plans, the health insurance lobby, released its own lengthy statement on Wednesday. In a letter to the leaders of the House committees that drafted the bill, Marilyn B. Tavenner, the group's chief executive, warned Republican leaders that their plans to change Medicaid financing, among other things, could harm coverage and care.
While many insurers have lost money in the Affordable Care Act's private insurance marketplaces, they have generally profited from the expansion of Medicaid, which would effectively be phased out under the Republican plan.
''As a core principle, we believe that Medicaid funding should be adequate to meet the health care needs of beneficiaries,'' Ms. Tavenner wrote. ''Medicaid health plans are at the forefront of providing coverage for and access to behavioral health services and treatment for opioid use disorders, and insufficient funding could jeopardize the progress being made on these important public health fronts.''
A day earlier, AARP -- the association of middle-aged and older Americans that is another crucial supporter of the Affordable Care Act -- declared its opposition to the bill and even started running an ad against it. In a letter to Congress, the group said the bill would increase health costs for people ages 50 to 64, could lead to cuts in Medicaid coverage of long-term care and would allow insurers to charge older people five times as much as younger ones.
The hardening resistance complicated the case for the Republicans as they moved their bill forward on Wednesday.
''I respect those organizations and their views,'' said Representative Larry Bucshon, an Indiana Republican and a heart surgeon who conceded that criticism of the bill from doctors and hospitals could make it more difficult to sell the measure to the public. ''Their voice is an important voice in health care.''
But, he noted, those groups supported the health care law in 2010.
''Hospitals have done quite well under the Affordable Care Act, but my constituents have not,'' he said. ''Their premiums are going up. Their deductibles are high.''
Across the rotunda, Republican senators were less enthusiastic.
Senator Shelley Moore Capito, Republican of West Virginia, said she was not certain that a delay in the rollback of Medicaid coverage was ''enough for me.'' Senator Lisa Murkowski, Republican of Alaska, expressed alarm that the bill's tax credits would not account for higher premium costs in insurance markets like hers, a largely rural state with little competition. Senator Marco Rubio, Republican of Florida, said he did not want states that took the Medicaid expansion to ''get a benefit'' that the states that rejected the program did not.
Senator Susan Collins, Republican of Maine, said she was unhappy that the bill removed money for Planned Parenthood.
There was also a creeping concern about how quickly the bill was moving. Senator Mitch McConnell of Kentucky, the Republican leader, essentially promised to move the bill to the Senate floor without the hearings and other processes that are normal for such a far-reaching piece of legislation. He had promised when Republicans took the majority that they would honor normal Senate processes and traditions.
''I think if that's the approach they take,'' Mr. Rubio said, ''they won't have the votes in the Senate.''
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URL: http://www.nytimes.com/2017/03/08/us/politics/affordable-care-act-obama-care-health.html
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GRAPHIC: PHOTO: Representative Kevin Brady of Texas, center, and other Republicans moved forward with the party's health care bill on Wednesday. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES) (A17)
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The New York Times Blogs
(Economix)
September 3, 2013 Tuesday
Testing a Premise on the Health Care Law and Part-Time Work
BYLINE: JARED BERNSTEIN
SECTION: BUSINESS; economy
LENGTH: 441 words
HIGHLIGHT: Recent statistics show that the incidence of involuntary part-time work is positively correlated with a state’s unemployment rate, evidence that it is the job market at work, not the Affordable Care Act, an economist writes.
Jared Bernstein is a senior fellow at the Center on Budget and Policy Priorities in Washington and a former chief economist to Vice President Joseph R. Biden Jr.
Since the Affordable Care Act requires businesses with at least 50 full-time workers to provide them with coverage (or it will, when the employer mandate kicks in a year from now), critics claim that it is prompting employers to shift to more part-time jobs. But as I have noted in variouspostings, there is no evidence to back up that claim - in fact, both involuntary and overall part-time work are declining as a share of all jobs.
That observation came back to me when I saw a clever post by the economist Dean Baker on restaurant jobs and unemployment by state (showing that states with weaker job markets were creating a larger share of lower-quality jobs). It would be a neat test, I thought, to see if the share of involuntary part-time workers was also correlated to the unemployment rate by state. I'd expect that correlation to be positive - that states with higher unemployment would have higher shares of involuntary part-timers - providing further evidence that it is the job market, not the health care law, at work. Conversely, if the incidence of involuntary part-time work was uncorrelated with state unemployment rates, then the Affordable Care Act would be a more plausible candidate to explain the variation.
Thanks to David Cooper of the Economic Policy Institute, my computer was soon feasting on employment data for the first half of this year. And as you see in the chart below, the data showed a positive relationship between unemployment rates and the involuntary part-timers' share of employment.
(For those who like the statistical weeds, the regression coefficient, or slope of that line, is 0.46, and highly significant, at t-stat=5.59. That means that we would expect a state with, say, 8 percent unemployment to have a share of involuntary part-timers that was 0.46 percentage points higher than a state with 7 percent.)
You want to hate on Obamacare, I can't stop you. And the incentive to reduce workers' hours may someday be found in the data, though according to the administration, fewer than 1 percent of employees have weekly hours slightly above the 30-hour cutoff, are employed by businesses affected by the employer mandate and do not already have health insurance.
But the fact is that for now, there's nothing to see here, folks. Move along, please.
What Job-Sharing Brings
Full Time, Part Time, Good Jobs, Bad
The New Economics of Part-Time Employment, Continued
Working Parents, Wanting Fewer Hours
Yes, the Sequester Is Affecting the Job Market
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(Economix)
June 12, 2013 Wednesday
The New Subsidy for Layoffs
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 897 words
HIGHLIGHT: It seems likely that the Affordable Care Act will induce more people to retire and more employers to lay workers off, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
A major provision of the American Recovery and Reinvestment Act helps predict what will happen in the insurance market next year.
Employees and employers often take steps to avoid layoffs, like working hard to encourage customers and clients to continue buying the goods and services provided by the business.
Sometimes layoffs are not avoided by such efforts, which is why many employers also take steps to ease the burden of a layoff on employees and their families and to minimize disputes between them and the employer. Many businesses voluntarily offer cash severance pay, which is intended to replace the usual paycheck for several weeks or months after the layoff, depending on the length of time that the employee had been with the company. (During the time of unemployment, the former employee can many times collect both the severance pay and state unemployment insurance benefits.)
Employers may also offer to help laid-off workers continue with their health insurance during the unemployment spell. (Indeed, a laid-off worker who intended to spend some severance pay on health insurance premiums would save money on taxes if the former employer were paying those premiums, even if it meant lower severance.) Severance pay and health insurance costs for former employees are significant expenses that employers presumably take into account when they decide the number and timing of their layoffs.
During 2009 and 2010, the American Recovery and Reinvestment Act had the federal government pay some costs of layoffs, especially with its premium-assistance program, which paid 65 percent of the premiums that a laid-off employee would pay to stay on the former employer's health plan. People who could join a spouse's employer health plan and people without health insurance on their previous job were ineligible for the program.
Economists understand this premium assistance to be a subsidy to layoffs, making them cheaper and less of a burden. Employers saw it this way, too, according to an Urban Institute study.
"Some large-firm interviewees reported that before A.R.R.A. they provided some amount of free or reduced cost Cobra coverage for laid-off workers, based upon the prior duration of employment," the study found, referring to the Consolidated Omnibus Budget Reconciliation Act, which allows workers who have lost their jobs to purchase coverage. "Several of these companies reported that they reduced or dropped this prior benefit in reaction to A.R.R.A."
Although we will learn more when (and if) the United States Treasury releases its final report on the premium-assistance program, it appears that program participation was high. An interim report indicated that perhaps two million households and even more individuals had their health insurance subsidized within nine or 10 months of starting the program.
The law's premium assistance program ended in 2010, but significant amounts of premium assistance are coming next year as a part of the Affordable Care Act. For families with income between 100 and 250 percent of the poverty line, the Affordable Care Act is even more generous than the Recovery Act, because it helps them pay for both health insurance premiums and out-of-pocket costs like co-payments and deductibles. Also, health insurance is more expensive now than it was in 2009, which makes a percentage subsidy that much more valuable.
Moreover, unlike the Recovery Act's program, next year's program welcomes people out of work even if they left work by quitting, retiring or being fired for cause. It also welcomes people who have the and people who had no health insurance on their prior job.
Thus, we are about to begin a federal program that subsidizes layoffs to a degree that we have not seen before. Nevertheless, economic and budget forecasts by the Congressional Budget Office and others have yet to consider the effects of the layoff subsidy on the size of the program and the number of layoffs that will occur.
The C.B.O. has concluded that 800,000 people will take early retirements or quit as a consequence of the Affordable Care Act, not from its premium assistance, but based on the assumption that the unsubsidized nongroup health insurance market will operate better. The C.B.O. still needs to estimate how many people will be laid off as a consequence of the new subsidy to layoffs.
Over all, the C.B.O. predicts that 11 million people will receive premium assistance in 2015 (and even fewer in 2014), the vast majority of whom would be employed or dependents of an employed person. Yet the Recovery Act's experience suggests that three million or four million people will receive premium assistance through unemployment alone, not to mention the millions more that receive it while working.
Be prepared for some unpleasant surprises over the next year or two, both as to the amount that the labor market is depressed and the unanticipated federal spending that will be needed to provide the benefits promised by the Affordable Care Act.
Affordable Care Act Could Be Good for Entrepreneurship
Massachusetts Employees Will Keep Their Health Plans
Patterns of Changes in Health Insurance
Health Coverage Worthy of a Senator
Hammurabi's Code and U.S. Health Care
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The New York Times
February 11, 2017 Saturday
Late Edition - Final
Senate Splits as New Chief Takes Over Health Dept.
BYLINE: By ROBERT PEAR and ALAN RAPPEPORT
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1007 words
WASHINGTON -- President Trump's secretary of health and human services, Tom Price, took office on Friday with a promise to fix what he called a ''broken health care system'' that was ''harming Americans and their families.''
Mr. Price was sworn in by Vice President Mike Pence just hours after the Senate, by a party-line vote of 52 to 47, confirmed his nomination in the early hours of Friday morning.
Republicans said that Mr. Price, 62, an orthopedic surgeon, would bring a physician's insights to managing a federal agency that they said had become addicted to heavy-handed federal regulation and blind to problems spawned by the Affordable Care Act, also known as Obamacare.
''Dr. Price has a thorough understanding of health care policy and the damage that Obamacare has caused,'' said Senator Lamar Alexander, Republican of Tennessee, where consumers this year saw rate increases averaging 44 percent to 62 percent in the law's marketplace.
Mr. Alexander, the chairman of the Senate health committee, said Mr. Price would be ''an excellent partner'' as Congress tries to devise a replacement for the health care law championed by former President Barack Obama.
Senate Democrats and the chamber's two independents said they feared the worst, based on Mr. Price's 12-year record as a Republican member of the House of Representatives from Georgia. They said that Mr. Price had led efforts to repeal the health care law and slow the growth of Medicare and Medicaid by shifting some costs to beneficiaries and trimming payments to some health care providers.
''This is a sad evening,'' said Senator Chuck Schumer of New York, the Democratic leader. ''People will look back and say that the Republicans' war on seniors began at 2 a.m. Friday morning when the Senate unfortunately confirmed Representative Price.''
The depth of concern about Mr. Price was illustrated by the comments of Senator Angus King, independent of Maine, who caucuses with Democrats but is not given to hyperbole.
''To put somebody in charge of the Department of Health and Human Services that is inimical to Medicare, Medicaid and the Affordable Care Act -- this guy is a wrecking ball,'' Mr. King said. ''He is not a secretary. He is going into this agency to destroy it. He wants to undercut and diminish and, in some cases, literally destroy some of the major underpinnings of providing health care to people in this country.''
By contrast, at the swearing-in ceremony, the vice president said Mr. Price had emerged as ''the most principled expert on health care policy in the House of Representatives, if not the entire Congress.''
Mr. Trump said again on Friday that the Affordable Care Act was ''a total and complete disaster.'' With the confirmation of Mr. Price, he said, the administration will ''get down to the final strokes,'' devising a plan that can provide ''tremendous health care at a lower price.''
In a farewell address to the House submitted for publication in the Congressional Record, Mr. Price said that, as chairman of the Budget Committee, he had begun an important effort to ''fix our nation's broken health care system'' and ''get Washington out of the way'' of patients and doctors.
One of the first challenges facing the new secretary is to stabilize insurance markets and decide the future of financial assistance provided to insurance companies that say they have lost large amounts of money treating patients under the Affordable Care Act.
A judge on the United States Court of Federal Claims ruled on Thursday that the Obama administration had illegally reneged on a promise to pay subsidies to an Oregon insurer, Moda Health Plan. Many other insurers have filed similar claims. The Obama administration's failure to pay the claims was cited as a reason for the collapse of many nonprofit insurance cooperatives created under the Affordable Care Act.
In the Moda case, Judge Thomas C. Wheeler ordered the government to pay $214 million that the company was expecting under a program meant to limit insurers' losses in their first few years operating under the Affordable Care Act. Federal officials' failure to keep their promise was ''hardly worthy of our great government,'' the judge wrote.
The Trump administration has not decided whether to appeal the decision.
The next prospective member of Mr. Trump's cabinet to be voted on will be Steven T. Mnuchin, the Treasury secretary nominee, on Monday evening.
Congressional reaction to Mr. Mnuchin, as to Mr. Price, has been divided along party lines. Republicans have been impressed with the former Goldman Sachs banker's business acumen, while Democrats have argued forcefully that he is ill-equipped to steer America's economy.
Those divisions were on stark display during Mr. Mnuchin's confirmation hearing at the Senate Finance Committee last month, when Democrats questioned him over his business record and ultimately boycotted votes on his nomination.
The most significant concern among Democratic critics of Mr. Mnuchin was that he failed to disclose nearly $100 million of his assets and that he did not mention his role as a director of an investment fund based in the Cayman Islands, a well-known tax haven.
Mr. Mnuchin has also been accused by Senate Democrats of lying to Congress when he said during his hearing that OneWest Bank did not engage in the foreclosure practice of ''robo-signing'' when he was its chief executive. Local news reports suggested that the bank did engage in such practices in some states.
Senator Elizabeth Warren, Democrat of Massachusetts, said on Friday that such discrepancies should disqualify Mr. Mnuchin, who she said was unlikely to look out for working-class Americans.
''There's nothing in Mr. Mnuchin's record to suggest that he would want to stand up to Wall Street,'' Ms. Warren said in a speech on the Senate floor. ''Mr. Mnuchin is the ultimate Wall Street insider.''
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URL: http://www.nytimes.com/2017/02/10/us/politics/tom-price-health-secretary-senate.html
LOAD-DATE: February 11, 2017
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GRAPHIC: PHOTO: Tom Price during his confirmation hearing in January. On Friday, Vice President Mike Pence swore Mr. Price in as secretary of health and human services. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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The New York Times
March 28, 2017 Tuesday
Late Edition - Final
After Health Bill Defeat, What's Next?
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 591 words
To the Editor:
Re ''Trump Becomes Ensnared in Fiery G.O.P Civil War'' (front page, March 26):
With the defeat of the Republican effort to repeal and replace the Affordable Care Act, President Trump now faces what your article calls a ''wrenching choice: retrenchment or realignment.'' For a man with no true party affiliation or ideology, the choice should be simple.
He could shake up the political system as he promised during his campaign by demanding that Democrats and Republicans work together on a bipartisan committee to fix what needs mending in the Affordable Care Act while maintaining what has allowed 20 million more Americans to get health care. This would be a win-win for the country and for Mr. Trump, who could rightly say he put the concerns of the men and women who elected him over party politics.
For once, when he said he had done something great, he would be speaking the truth.
SUSAN SHELTON, FALMOUTH, MASS.
The writer is a psychiatrist.
To the Editor:
While pundits attribute the withdrawal of the American Health Care Act to President Trump and Speaker Paul Ryan's failure in leadership, I view it as a triumph of democracy. The bill, which privileged the rich at the expense of women, the poor, older people and much of the middle class, was clearly unacceptable to the American people. We protested, bombarding congressional offices with emails, phone calls and letters. The professional politicians' fear of losing their seats in 2018 was palpable, hence the withdrawal of the bill.
Thank God Mr. Trump and Mr. Ryan were not successful. It would have been a bitter day for America if they had been.
SUSAN WHITCOMBSOUTHPORT, CONN.
To the Editor:
President Trump knows how to make a deal with those who want to make a deal with him. He doesn't know how to make a deal with those who don't want to make a deal with him. That's the difference between business and politics.
JAMES SUTTON, DES MOINES
To the Editor:
Now that the Republican health bill has been withdrawn, it's a great opportunity for the Democrats. They can show the nation that they are a responsible participant in the legislative process, more than an opposition party of ''no.'' They should propose a health bill that deals with the acknowledged weaknesses in the Affordable Care Act.
HERB HOEFER, PORTLAND, ORE.
To the Editor:
I'm pleased that the Republicans' proposed health care reform/tax cut for the rich failed. But, somehow, I don't feel like celebrating. I suppose it's because I can't help wishing that President Barack Obama had a bit of the uncompromising spirit of the Republicans' Freedom Caucus back when he was promoting his Affordable Care Act.
Perhaps, then, Obamacare would have kept the public option. That would have discouraged Republican-controlled states from refusing the act's Medicaid expansion and private insurance companies from withdrawing from state insurance exchanges knowing that the federal government could step in with a single-payer alternative.
Not only would this have benefited millions of Americans by expanding health care coverage, but it would also have deprived Republicans of a major issue in the presidential election.
JOHN E. STAFFORD, RYE, N.Y.
To the Editor:
O.K. We voters spoke out for affordable health care. Now we have to do the same for environmental protection and our public schools -- and the list goes on as the ''wreckers'' President Trump put at the head of each government agency try to take away what we voters know we must keep.
SAYRE SHELDON, CAMBRIDGE, MASS.
URL: http://www.nytimes.com/2017/03/27/opinion/after-the-health-bill-defeat-whats-next.html
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The New York Times Blogs
(In Practice)
September 26, 2013 Thursday
Tracking the Affordable Care Act
BYLINE: The New York Times
SECTION: US
LENGTH: 116 words
HIGHLIGHT: To coincide with the rollout of the Affordable Care Act, The Times is starting a new feature that will track the law’s implementation through articles, graphics, Q. and A.’s, explanatory items and other elements contributed by Times reporters and editors.
On Oct. 1, Americans can begin to sign up for health coverage through the online insurance marketplaces, or exchanges, created under the Affordable Care Act.
The exchanges are designed to make health care more widely available and affordable for millions of people nationwide and are a centerpiece of the Obama administration's much-debated health care law.
To coincide with the rollout, The Times is starting a feature that will track the law's implementation through articles, graphics, Q. and A.'s, explanatory items and other elements contributed by Times reporters and editors.
We will also seek to gauge public reaction through reporting, public opinion surveys, online commentary and social media.
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The New York Times Blogs
(You're the Boss)
September 11, 2014 Thursday
Small Businesses See Only a Small Increase in Health Premiums
BYLINE: Robb Mandelbaum
SECTION: BUSINESS; smallbusiness
LENGTH: 855 words
HIGHLIGHT: Even with a smaller-than-expected increase in premiums, however, the share of small businesses offering health insurance to employees declined slightly.
The warnings this time last year were dire and widespread: Small businesses would face a double-digit rise in health care costs in 2014. But as it turned out, premiums for small businesses barely budged. According to the Kaiser Family Foundation's 2014 Employee Health Benefits Survey, small-group health insurance premiums for individual coverage grew by just 1 percent this year, the slowest rate of growth since 2008. Family plans increased by 2 percent.
This relatively good news did not induce more small businesses to begin offering their employees coverage, however - in fact, the share of small companies offering insurance to employees actually fell, if only slightly. Only 44 percent of companies with fewer than 10 employees offered insurance in 2014, down from 45 percent last year and the lowest level since Kaiser began keeping track of this in 1999. Among companies with fewer than 200 workers, the rate was 54 percent.
Gary Claxton, a vice president at the Kaiser Family Foundation, said that statistically speaking, the change in offer rates was not significant. But the findings come as more experts suggest that companies are likely to stop offering employees insurance, now that the Affordable Care Act has made individual insurance a more attractive alternative. (In addition to requiring more comprehensive coverage from individual policies and prohibiting medical underwriting, the law also gives subsidies to people who cannot afford the insurance.)
Small companies would seem to be especially good candidates for dropping coverage, because their employees are more likely to be eligible for subsidies for individual insurance, and because the Affordable Care Act imposes new benefits and cost-sharing standards on small-group insurance, which some people have said would drive up costs.
In fact, according to Mr. Claxton, premiums grew slowly because underlying health care expenses have remained low - people have been using fewer services in recent years - despite the grim predictions from insurance carriers. "I think they're having a hard time convincing their customers that they need to raise prices," he said. "Or they know that their customers are going to shop if they try to raise prices too much."
Moreover, he said, "under the Affordable Care Act, at least in the small group market, if you make too much money you have to give some of it back in rebates. So maybe that had an effect as well." In addition, many small businesses managed to evade the health law's new requirements by renewing existing plans, which did not have to comply with the law.
But critics of the new law still say higher premiums are coming. "I see this as kind of the calm before the storm, really," said Holly Wade, a senior policy analyst at the National Federation of Independent Business, which has fought the Affordable Care Act on Capitol Hill and in court. "Because the law's rollout has been so chaotic, with so many delays and so many extensions, we really haven't seen the full impact on rate increases."
Ms. Wade pointed to a new government study that predicted sharper growth in health care expenses beginning this year. "Combining that with states eliminating noncompliant plans over the next two years, we'll start seeing a rapid increase in the cost of health insurance premiums," she said.
Other longstanding trends in small company health coverage maintained their trajectory in the latest Kaiser study. Employers are offering insurance to fewer employees, and fewer eligible workers are taking that coverage. Employees are paying more out of pocket - fully 61 percent of covered employees are paying a deductible of at least $1,000. (Mr. Claxton said that these higher deductibles and other out-of-pocket costs partly explained why consumers are using less health care.) And the share of employees in so-called grandfathered plans - health plans in place before the law's passage in 2010 that are exempted from many of its requirements - has fallen steadily, from 63 percent in 2011 to 35 percent this year. Grandfathered plans are distinct from noncompliant plans that businesses were able to renew early last year, and the study did not track how many businesses did that.
It did, however, track how many businesses tried to use the new insurance marketplaces for small businesses created by the Affordable Care Act. Some supporters of the health law argued that these SHOP exchanges, as they are called, would drive premiums down by making the industry more transparent and competitive. But the SHOP exchanges were troubled by broker indifference and repeated delays as some states and the federal government focused on fixing the broken individual exchanges.
The Kaiser survey confirmed the SHOP exchanges' overwhelming irrelevance. Among companies with up to 75 employees that went shopping for insurance but ultimately decided not to offer it, only 13 percent looked at buying coverage through an exchange. Only 12 percent of companies that did offer coverage considered using the SHOP exchange. And in the end, only 2 percent of those 12 percent went ahead and bought the insurance through the exchange.
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The New York Times
April 3, 2012 Tuesday
Late Edition - Final
The ABC's of the Health Care Law and Its Future
BYLINE: By GINA KOLATA
SECTION: Section D; Column 0; Science Desk; Pg. 5
LENGTH: 990 words
After the contentious arguments before the Supreme Court last week, the future of President Obama's Affordable Care Act is far from certain. The legislation is enormously complex, with thousands of pages of provisions, but at its center is a controversial requirement that all Americans purchase health insurance. The justices will decide whether the so-called individual mandate is constitutional, and if not, whether the entire law must be overturned.
We spoke to Jonathan Oberlander, author of ''The Political Life of Medicare'' and a professor of social medicine and health policy and management at the University of North Carolina, Chapel Hill, about the law and its future. This conversation has been condensed and edited for space.
As briefly as possible, what is the Affordable Care Act?
It's a series of policies and regulations and subsidies and mandates. That's the reason it's so complex. It builds on an incoherent medical system with all kinds of public and private insurance and tries to patch the holes. And it affects different groups of Americans in different ways at different times.
But it is transformative. If it is implemented, it would be the most important health care law since the enactment of Medicaid and Medicare in 1965. It brings us closer to the ideal that all Americans should have access to care regardless of income or health status.
Can the act be carried out without requiring almost everyone to buy health insurance?
That would be a serious wound, but it would not be fatal. There are many parts of the act, including the expansion of Medicaid, that could be implemented and that have little to do with the mandate. But without the mandate, the Affordable Care Act would cover fewer people and would not be as effective. And it will raise questions about the stability of the health insurance exchanges.
My guess is that if the whole law is thrown out we will see a return to incrementalism, doing small things like expanding Medicaid by a little bit or giving very modest tax credits to some uninsured. Or we will see federalism -- turning things over to the states. Or doing nothing, which has been our default for much of the past century.
How you can have health insurance exchanges without a mandate? Wouldn't the healthy shun them until they become sick, forcing the exchanges to charge prohibitive rates?
There are other things that you can do, but chances are Congress won't do them. You can tell the insurers that they can charge a penalty to people who do not sign up at first and try to enroll later. It could be like what happens with Medicare prescription drug coverage -- if you try to sign up after you are eligible, you pay a higher premium for the rest of your life.
So if the mandate is thrown out, what about other kinds of insurance? Medicare is deducted from my paycheck, right?
One of the things that even the conservative justices said is that tax-financed national health insurance is permissible. That's why Medicare is O.K. It is a tax, and Congress has the authority to raise revenue. The mandate would require people to purchase private insurance.
In fairness to the Obama administration, at the time the Affordable Care Act was proposed there was an overwhelming legal consensus that the mandate was constitutional. The idea has been around for decades -- it was originally a conservative Republican idea as an alternative to national health insurance -- and few had raised serious constitutional issues.
If the law stands more or less intact, when will we see some big changes? So far, what has happened seems less than transformative.
June will be the big earthquake. (That is when the Supreme Court will announce its decision.) The next big month is November, with the election. If the law survives those two big challenges, legal and political, the big year is 2014. That is when most of the major changes go into effect.
States will be required to expand Medicaid. All Americans making up to 138 percent of the poverty line -- that's about $15,000 today for an individual -- will be eligible for Medicaid. Historically, Medicaid has been linked to demography. It is not enough to be poor. In most states you have to be a pregnant woman, a child, elderly or disabled to be eligible. The A.C.A. will change that.
In addition, insurance subsidies will be made available to help the uninsured and some workers in small businesses buy private insurance through insurance exchanges. Small businesses can buy insurance there, too.
Insurers will be prohibited from denying coverage or charging higher premiums to persons with pre-existing conditions. And most Americans will be required to obtain -- and larger businesses will be required to offer -- health insurance or pay a penalty.
Doesn't the Affordable Care Act contain a lot of proposals to get costs under control, like comparative effectiveness studies and reimbursing doctors based on their performance? Will such ideas help contain the cost of medical care?
Most of these ideas are wishful thinking. The evidence is either mixed or just not there that these reforms will rein in spending. They are a sort of faith-based cost control. Other options are more painful, and at the moment there may not be any method for controlling spending that is politically feasible.
The A.C.A.'s capacity to produce reliable cost containment has been exaggerated. Its Medicare savings are significant -- it will save an estimated $500 billion in the next decade by slowing payments to hospitals and private insurance plans that contract with Medicare. Outside of Medicare, the cost containment is less impressive.
Do you foresee big changes in the near future -- politically difficult decisions that will rein in costs?
I'm a Red Sox fan, so I believe in miracles. But in the short term, the answer is no. We will build on our existing system -- it's what we have, and it is too difficult to move away from it. Two or three decades from now, nobody knows.
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March 23, 2014 Sunday
Late Edition - Final
A Four-Year Checkup for the Health Care Law
SECTION: Section SR; Column 0; Sunday Review Desk; ROOM FOR DEBATE; Pg. 8
LENGTH: 2891 words
Four years ago, President Obama signed the Affordable Care Act into law. Is the law working? What needs to be fixed? And what is beyond repair?
It's Working Despite Misinformation
By Robert Reich
Robert Reich, the secretary of labor in the Clinton administration, is Chancellor's professor of public policy at the University of California, Berkeley and the co-creator of the film "Inequality for All."
Early indications are the Affordable Care Act is working. With less than two weeks remaining before the March 31 deadline for coverage this year, five million people have already signed up. After decades of rising percentages of Americans lacking health insurance, the uninsured rate has dropped to its lowest levels since 2008.
Meanwhile, health care costs have slowed dramatically. The new law may well be contributing to this slowdown by reducing Medicare overpayments to medical providers and private insurers, and creating incentives for hospitals and doctors to improve quality of care.
But a lot about the Affordable Care Act needs fixing -- especially the widespread confusion and misinformation that continues to surround it. For example, a majority of business owners with fewer than 50 workers still think they're required to offer insurance or pay a penalty. (In fact, the law applies only to businesses with 50 or more employees who work more than 30 hours a week). And many companies with fewer than 25 workers still don't realize that if they offer plans they can qualify for subsidies in the form of tax credits.
Many individuals remain confused and frightened. Forty-one percent of Americans who are still uninsured say they plan to remain that way. They believe it will be cheaper to pay a penalty than buy insurance. Many of these people are unaware of the subsidies available to them. Signups have been particularly disappointing among Hispanics.
Some of this confusion has been deliberately sown by outside groups that, in the wake of the Supreme Court's ''Citizen's United'' decision, have been free to spend large amounts of money to undermine the law. For example, Republican Gov. Rick Scott of Florida told Fox News that the Affordable Care Act was ''the biggest job killer ever,'' citing a Florida company with 20 employees that expected to go out of business because it couldn't afford coverage.
None of this is beyond repair, though. As more and more Americans sign up and see the benefits, others will take note and do the same. The biggest problem on the horizon that may be beyond repair -- because it reflects a core feature of the law -- is the public's understandable reluctance to be forced to buy insurance from private, for-profit insurers that aren't under enough competitive pressure to keep premiums low.
But even here, remedies could evolve. States might use their state-run exchanges to funnel so many applicants to a single, low-cost insurer that the insurer becomes, in effect, a single payer. Vermont is already moving in this direction, and California may be next. In this way, the Affordable Care Act could become a back door to a single-payer system -- every conservative's worst nightmare.
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Deterring, and Losing, Those Who Are Needed
By Gail Wilensky
Gail Wilensky is a senior fellow at Project HOPE. She directed the Medicare and Medicaid programs from 1990 to 1992 and was a senior health and welfare adviser to President George H.W. Bush.
Getting people in their 20s to put up their own money for health insurance would be enough of a challenge -- there's a reason they're called the ''young invincibles'' -- without charging them premiums that are higher than is actuarially appropriate. But under the Affordable Care Act, that's exactly what the government is doing. Premiums for the youngest, healthiest age group cost no less than one-third of that allowed for the oldest group, which uses the most health care. In truth, premiums for the youngest should be more like one-fifth. Limiting the price variation was done to subsidize the population that would soon be entering Medicare, but it comes at the expense of increasing costs for young adults.
This problem is compounded by requiring a comprehensive package of benefits that are desirable by some but less desirable by many younger people and, also, increases the price of insurance. The combination of artificially high prices, broad benefit packages and the promise that young adults who don't buy insurance now can do so in the future without penalty, even if they develop major health problems, is making it harder to persuade reluctant buyers to get insurance.
A longer term concern is that subsidies for most people vary depending on whether their insurance comes through their employer or an exchange, encouraging people to look for the best deal, even if that means getting their employers to drop their coverage, and creating instability in the process.
What's the problem? Dropping employer-sponsored insurance for a higher subsidy, paid for by the government, would increase the overall program cost.
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Get Rid of the Individual Mandate
By Uwe E. Reinhardt
Uwe E. Reinhardt is a professor of political economy, economics and public affairs at Princeton University. He has some financial interests in the health care field.
Every actuary and economist will attest that ''community-rated'' health insurance premiums unrelated to an individual's health status work properly only if accompanied by a mandate on all individuals to have insurance for the covered benefit package. Absent that mandate, risk pools will consist mainly of sick people, premiums will go sky high and the insurance system will dive into a death spiral.
The Affordable Care Act of 2010 mandates insurers quote community-rated premiums for applicants of a given age, but it accompanies that stricture with only a weak, half-hearted mandate on individuals to be insured. It invites an insurance executive's actuarial nightmare. So I say, eliminate the mandate and replace it with a better option.
Americans tend to bristle at government mandates of any sort. A superior approach therefore would be a form of nudging, originally proposed in 2009 by my Princeton colleague Paul Starr. Individuals would be free to remain uninsured after March 31, but for another X years they would be barred from potentially federally subsidized coverage at community-rated premiums available under the Affordable Care Act.
Starr suggested that X be 5. In my view that is much too lenient.
In a column in this paper's Economix blog, I proposed that by age 25 an individual had to choose whether she or he would join a health insurance system based on social solidarity, with community-rated premiums, or instead join a system for rugged individualists, with medically underwritten premiums based on health status.
Only under the most dire economic circumstances would rugged individualists in this scheme ever be allowed into, say, Medicaid, to avoid human suffering that could be mitigated by critically needed health care. But thereafter the individual would not be allowed to accumulate any assets or enjoy income above the poverty level until he or she had paid back all premiums from age 25 on.
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A Plain and Simple Success
By Toni Miles
Toni Miles is the director of the Institute of Gerontology and a professor of epidemiology and biostatistics at the University of Georgia's College of Public Health. She is the author of "Health Care Reform and Disparities: History, Hype, and Hope."
The Affordable Care Act was designed to translate policy into law. Its foundation is reformation of health care insurance financing. This is a cumbersome process, hence the length and complexity of the law.
From 2008 to 2010, I was a health and aging policy fellow on the Senate Finance Committee where I witnessed the birth of this legislation as it tackled health care financing and ways to fix the employer-sponsored health insurance market.
To understand what works about the Affordable Care Act, it is important to fully appreciate that in the United States, our only access to health care is through insurance, and approximately 70 percent of Americans obtain health insurance through employer-sponsored plans -- plans found in the private insurance markets.
Before the health care law, newly widowed or divorced adults -- 24 percent of women and 30 percent of men between the ages of 18 and 64 -- had few options for access to health insurance. (I include divorced adults because many married couples obtain health care insurance through one spouse's employer plan.) It is painful enough to lose a spouse through death or divorce but to find out that you've also lost your health insurance can be financially overwhelming.
Now that we have the Affordable Care Act and the health insurance exchanges, these people who are not eligible for Medicare have reasonable alternatives. This is a good thing.
If there is one bright, shining success from this law, this is it.
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Centralized Power Saps Fairness and Innovation
By James C. Capretta
James C. Capretta is a senior fellow at the Ethics and Public Policy Center and a visiting fellow at the American Enterprise Institute.
Most of the Affordable Care Act's most significant aspects were scheduled to take effect at the beginning of 2014, but even now, we are not seeing full implementation.
That's because the president has unilaterally delayed and rewritten many of the law's key provisions, including the employer mandate, the application of the individual mandate (under certain circumstances) and the enforcement of certain new insurance rules.
Among other things, these alterations of the law raise issues of fairness. By essentially deciding to look the other way and permit the continued sale of certain insurance policies in the individual insurance market that violate the requirements of the law, the administration will only help people in states that go along with this legally dubious work-around and whose former insurers are willing to reopen the disallowed plans. This supposed fix leaves millions of Americans out, which means they won't get to keep the plans they had and liked after all.
Similarly, the president has suspended the individual mandate tax for persons with policies in 2013 that were canceled due to new insurance requirements in the law. But this tax clemency does not extend to persons who are arguably even more sympathetic because they couldn't afford coverage at all in 2013 and were therefore uninsured. The lesson to be drawn here is that a law as consequential as health care reform should not be written in a way that allows the executive to effectively rewrite it in an ad hoc and discriminatory manner. It invites bending the rules and pushing legal boundaries for political reasons.
It is also evident that the law's huge concentration of power in the Department of Health and Human Services is, and will be, a serious mistake. This department now can make every important decision in the health insurance sector, and it is gradually accumulating power over the organization of the medical delivery system too. Consequently, the health system is responding to the steady flow of H.H.S. pronouncements, rather than to private initiative. Over time, as recognition spreads that the federal government is now calling all of the shots in the health system, innovation and adaptation will suffer, and, in time, so too will the quality of American medicine. Instead of taking the initiative to seek or deliver higher value care, the key players -- employers, providers, states and consumers -- will look first to see what the government requires to ensure reimbursement for services. The result will be a steady increase in federal bureaucratic control, and a commensurate decline in the quality of American medicine.
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We Must Keep Coverage Affordable
By Karen Ignagni
Karen Ignagni is the president and chief executive of America's Health Insurance Plans, a lobbying firm that represents the insurance industry.
For the first time, millions of Americans across the country have the peace of mind that health insurance provides. But more needs to be done to ensure coverage is affordable so that the expanded access to health insurance is sustained.
First, policymakers need to address provisions in the health care reform law that are at odds with the goal of affordability. For example, the new health insurance tax, which took effect this year, is increasing by an eye-popping 40 percent next year and will add nearly $400 to an average family's health care costs in 2015. This tax makes coverage more expensive and should be repealed. Second, policymakers must resist the temptation to limit new payment arrangements and benefit design flexibility that enable health plans to offer affordable coverage options to consumers. High-value provider networks are part of the broad array of strategies health plans use to ensure consumers receive the best value for their health care dollars. These networks are made up of a smaller number of doctors and hospitals that have a track record of providing the highest quality and most cost-efficient care to patients. A recent McKinsey analysis found that policies with high-value networks had premiums that were 26 percent lower than comparable options with broader networks. Unfortunately, politicians at the state and federal level are considering proposals to limit these initiatives and other efforts that individuals and families rely on for affordable premiums. Now the debate needs to focus on how to keep coverage affordable. Any provision in the law that is at odds with that goal should be changed. New proposals that would undermine affordability should be rejected.
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The Beginning of a Health Care Revolution
By Ezekiel J. Emanuel
Ezekiel J. Emanuel is an oncologist, contributing New York Times opinion writer and the author of ''Reinventing American Health Care.'' Andrew Steinmetz, Dr. Emanuel's research assistant, contributed to this post.
The inept roll out of the federal exchanges and the postponed implementation of various provisions create the impression that the Affordable Care Act -- which I helped design as an adviser to the Obama administration -- is failing. Actually, after 4 years it has produced real progress in access, quality and cost that has largely gone unnoticed. More important, the law created two structures that will significantly improve the American health care system.
The first is the exchanges, which are marketplaces that allow individual Americans -- not their employers -- to determine what health insurance they want at what price. Already, they are changing how Americans get health insurance. By the end of open enrollment on March 31, between 5.5 million and 6 million Americans will have signed up on an exchange. The shopping experience will continue to improve. Tax credits will enable more Americans to afford coverage. Over time, more workers will buy insurance directly on the exchange.
This will be a good thing. On the exchanges, you get to choose what works best for you. And options are plentiful. In New York's Westchester County, for instance, my research indicates that there are 16 silver plans from 7 insurers, and 54 plans overall.
The second structure is the accountable care organization, which are collections of doctors and hospitals that are paid to coordinate care, eliminate unnecessary tests and treatments, and keep people healthy and out of the hospital. Today there are more than 400 of these organizations working with Medicare and private insurers. Some, like Montefiore in the Bronx, are figuring out how to provide care at higher quality and lower cost.
Most important, these organizations and exchanges will combine to control costs long term. Over the last three years health care cost growth has slowed significantly. Part of this slowdown is due to the Great Recession. Part is due to higher deductible health plans making Americans more cost conscious. But part is also the Affordable Care Act. Americans have shown they prefer lower premiums. Indeed, 81 percent have selected lower-premium bronze and silver plans. This will induce insurers to compete by offering lower cost plans that deliver high value. In turn, to be included in silver and bronze networks, expensive hospitals and physicians will lower their prices and others will incorporate the ''secret sauce'' of successful accountable care organizations reducing costs overall.
The Affordable Care Act has already succeeded in providing Americans an efficient marketplace to shop for health insurance. By 2020, it will have induced a health care quality and efficiency revolution. That is success.
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This is an excerpt from Room for Debate. Other responses to the question are at nytimes.com/roomfordebate.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/roomfordebate/2014/03/20/obamacares-four-year-checkup
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August 18, 2015 Tuesday
Scott Walker's Health Care Plan Relies on Tax Credits to Buy Coverage
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 761 words
HIGHLIGHT: Gov. Scott Walker’s health care plan makes a full repeal of Obamacare his top priority, then proposes a system of tax credits that would allow Americans who do not get health insurance through their employers to buy individual plans.
"Repeal and replace" has been a mantra for Republicans when discussing President Obama's health law. On Tuesday, Gov. Scott Walker, the Republican presidential candidate from Wisconsin, offered some details on how he would replace the Affordable Care Act if he is elected.
Mr. Walker's plan makes a full repeal of the law his top priority, then proposes a system of tax credits that would allow Americans who do not get health insurance through their employers to purchase individual plans. The credits would be based on age, and consumers could then decide what plan to purchase, if they opt to buy health insurance at all.
"On my very first day as president of the United States, I will send legislation to the Congress to once and for all repeal Obamacare entirely," Mr. Walker said in a speech in Minnesota.
Repealing the Affordable Care Act has been a rallying cry for Republicans since it was enacted without their support in 2010. Mr. Walker's detailed critique of the law and his plan to replace it by lowering taxes and offering consumers more freedom comes as he has been struggling in recent polls after a tepid debate performance.
Despite continuing resistance to the law, dismantling it would likely be a big challenge for a Republican president. The Obama administration said this month that the number of people without health insurance had continued to decline, dropping by 15.8 million, or a third, since 2013. Meanwhile, studies have shown that the law has helped to keep insurance premiums in check.
"If this vague grab-bag of conservative wish-list items is the best health plan the G.O.P. can come up with for the largest economy on earth, it's the clearest signal yet that Republicans like Scott Walker are out of ideas and out of touch," said Eric Walker, a spokesman for the Democratic National Committee.
Senator Marco Rubio shed some light on his own health care reform policy this week. The Republican from Florida would also promote tax credits as a way to make insurance affordable and create federally backed "high risk pools" in states so that the sick can buy insurance at reasonable prices.
In Wisconsin, Mr. Walker has been a staunch opponent of the Affordable Care Act and has resisted taking federal funds to expand Medicaid in the state. A report last year faulted him for costing Wisconsin $500 million in lost savings because of his opposition to the law, but the governor maintained that such reliance on federal money would have been a mistake.
"We believe confidently going forward this federal government is likely to renege from its promises on Medicaid to the states," he said last summer. "And we won't be exposed to that."
Mr. Walker vows to do away with the Affordable Care Act's requirement that Americans purchase health insurance. Instead, his plan would seek to limit insurance premiums by opening the market so that consumers can shop for plans across state lines, thus intensifying competition among insurance companies.
The proposal also calls for reforms to Medicaid and improvements to health savings accounts that would give patients more pretax money to pay their health bills.
"You're going to do more to manage your health care, and your health, not just your health care, if you have control over the those dollars," Mr. Walker said. "It's all about freedom."
Mr. Walker also tries to address the issue of covering people with pre-existing conditions, which was one of the most important reforms in the Affordable Care Act because of the prohibitive prices sick people often faced when trying to purchase health plans. He promises "additional reforms to insurance coverage laws" that would prevent companies from discriminating against people who find themselves ill and without health insurance. Federal funds would be distributed to the states to help people with these conditions buy coverage.
Many of Mr. Walker's proposals on overhauling the health care system have been mainstays for Republicans over the years, and his plan offers little insight into how its costs or effect on the economy would compare with Obamacare. But pointing to the success of Wisconsin's BadgerCare program for the poor, Mr. Walker said he was confident that a similar structure could work across the United States.
"My plan would roll back the damage done by Obamacare and when compared to the realities that existed before Obamacare, would not add to the deficit," he said.
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February 14, 2015 Saturday
Late Edition - Final
A New Fix for Obamacare
BYLINE: By GRACE-MARIE TURNER and DIANA FURCHTGOTT-ROTH.
Grace-Marie Turner is the president of the Galen Institute, a health-policy research organization. Diana Furchtgott-Roth is the director of the Economics21 program at the Manhattan Institute for Policy Research.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 23
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EARLY next month the Supreme Court will hear arguments in King v. Burwell, the latest significant legal challenge to the Affordable Care Act. The petitioners argue that under the statute, the federal government is not allowed to provide health insurance subsidies in the 37 states that have either declined or failed to establish their own exchanges.
Should the court decide in the petitioners' favor, most likely in June, critics in Congress will feel vindicated. But then comes the hard part: Congress must be ready with a targeted plan to help at least six million people who would quickly lose that federal assistance, and most likely their insurance.
While several Republicans in Congress have offered serious proposals to replace Obamacare, debating a wholesale replacement of the Affordable Care Act would take months, even years. But it is essential for Congress to move fast on a short-term solution. About 85 percent of people who bought plans on the exchanges receive subsidies, and most could not afford the policies without them. If fewer people are enrolled and new enrollments decline, premiums will rise, leading to the breakdown of the exchange markets.
If the Supreme Court decides that the Affordable Care Act means what it says -- that subsidies are available only if a state establishes its own exchange -- then President Obama's signature legislative initiative would be significantly weakened in two-thirds of the states.
Fortunately, there is a way out, one that President Obama, forced by the court to the negotiating table, might be willing to accept. The first step would be for Congress to pass legislation that would allow people to keep subsidies they have already received, and allow subsidies for existing policies to continue through this year so people don't immediately lose their existing coverage.
Then, beginning in 2016, instead of subsidies to individuals, the 37 states without exchanges could receive a new, capped allotment from the federal government that we call health checks. States could use the allocation to provide immediate premium assistance to people affected by the court decision, and similar checks could be extended to others who would need insurance afterward.
The money would be distributed using the same infrastructure used to disburse funds for the Children's Health Insurance Program, which covers nearly nine million children. States know how to manage this platform, and could use it to distribute insurance premium support. (The ''checks'' could, of course, be distributed as electronic credits to insurers, which would be applied on a monthly basis to offset the cost of insurance policies individuals select.)
This might sound like the same subsidies by a different name, but one advantage would be that health insurance policies supported by health checks would not be subject to the Affordable Care Act's mandates, taxes, insurance rules and benefit requirements.
Currently, to qualify for a subsidy under the act, a health plan must cover a long list of benefits, many of which unnecessarily increase costs. Under our plan, people could apply their allotments toward the purchase of any health insurance plans or policies approved by their state. States could decide what regulations were needed to protect consumers while still providing opportunities for less expensive policies unburdened by excessive regulation and mandates. Such flexibility would also increase enrollment rates: People would be more likely to purchase policies if they had options that cost less and better fit their needs.
Of course, in reality, should the court decide against the Affordable Care Act, there are other options. Some supporters of the law are encouraging President Obama to simply declare existing federal exchanges to be state exchanges or license them to the states -- a move that would further complicate an already ungainly law and already frayed executive-congressional relations.
Others say that the 37 states without federal exchanges would have no choice but to quickly establish exchanges so that residents didn't lose coverage, even if they were ardent opponents of the law. Some might, but it's a good bet that many wouldn't, at least not in time to prevent their citizens from losing coverage.
Health checks offer a politically palatable third way. They would return control over health insurance to the states, with new resources to help their residents. And they would preserve the Affordable Care Act's present extension of coverage, which would make them more palatable to the Obama administration.
There is no way to know how the Supreme Court will rule in King v. Burwell, but it is incumbent upon both parties in Congress to be ready for the fallout should it decide against the Affordable Care Act. Health checks offer a simple, practical answer, and a start toward further efforts to reform our health insurance system.
URL: http://www.nytimes.com/2015/02/14/opinion/a-new-fix-for-obamacare.html
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January 28, 2017 Saturday
Late Edition - Final
Health Act Is at Risk, but Get Coverage Anyway, Experts Say
BYLINE: By ANN CARRNS
SECTION: Section B; Column 0; Business/Financial Desk; YOUR MONEY ADVISER; Pg. 3
LENGTH: 750 words
THE final deadline for enrolling in health insurance for 2017 under the Affordable Care Act is on Tuesday. But with so much turmoil and uncertainty surrounding the law's future, should consumers bother to shop for coverage?
Yes, say policy experts and consumer advocates. Health plans -- and subsidies to help low-income consumers pay for premiums -- are in place for this year. Healthcare.gov and the state-based insurance marketplaces are open for business, for consumers who do not have job-based coverage and are seeking individual policies.
''They absolutely should sign up,'' said Sabrina Corlette, a research professor at Georgetown's Center on Health Insurance Reforms. Unless something drastic happens, she said, consumers should have coverage and, for those who qualify, help with premiums through the end of the year.
The outlook after that is murky, to say the least. President Trump and the Republican-controlled Congress are working to dismantle former President Barack Obama's signature health law, known as Obamacare. But ''repealing and replacing'' the law, which has expanded health insurance to an estimated 20 million people through individual marketplace plans and the expansion of state Medicaid programs, is complicated. Several proposals have been floated, but it's not yet clear which, if any, will prevail. And Congress has yet to confirm Tom Price, Mr. Trump's nominee to lead the Department of Health and Human Services, which oversees Healthcare.gov.
Advertisements for the enrollment deadline were to have run over the next few days, but the Trump administration pulled them back, which presumably could dampen the number of people who take advantage of the option.
While Republican lawmakers want to do away with the Affordable Care Act, doing so without offering an alternative for people covered under the law is politically perilous. So there is likely to be some sort of transition period from the current system to its successor -- whatever that may be.
''A key question will be how to move from the Affordable Care Act to a new system without threatening coverage for people who have already gotten it,'' said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health research group.
All that will play out in the coming months. But currently, coverage is available. ''If people need coverage now, they should get it,'' Karen Pollitz, a senior fellow with the foundation, said.
Some consumers have complained that premiums and out-of-pocket costs for marketplace plans are high, and doctor choices are limited. Still, the federal government estimates that nearly three-quarters of marketplace customers can find plans for less than $75 a month. And most marketplace shoppers qualify for financial help with their premiums.
''It's a good idea to take advantage of the opportunity to enroll now,'' said Elizabeth Hagan, senior policy analyst with Families USA, an advocacy group.
Ms. Hagan urged consumers to seek help from those known as health care navigators, who are available by phone and in person to help consumers sort through options. Daniel Bouton, program director at the Community Council of Greater Dallas, which offers health care enrollment assistance, said that demand for help remained high and that consumers had been booking appointments for throughout the weekend, including Sunday. (To find assistance locally, you can visit Healthcare.gov and click on ''Find local help.'')
Here are some questions and answers about 2017 coverage under the Affordable Care Act:
If I sign up by Tuesday, when will my coverage begin?
Coverage will begin March 1.
What if I don't sign up by Jan. 31?
You can't enroll in marketplace coverage or change plans after the deadline, unless you have a special circumstance, like losing job-based coverage, marrying or having a child.
Is there any chance that marketplace health coverage could be disrupted this year?
One outside possibility that health care experts are closely watching comes from a lawsuit known as House v. Burwell. The suit, filed by Republican members of the House of Representatives in 2014, challenges federal payments made to insurers to help low-income people pay for health coverage under the Affordable Care Act. Under certain situations, the suit could lead to a dismantling of the ''cost sharing'' payments, causing insurers to pull back from marketplace coverage this year. The suit is delayed until Feb. 21.
Email: yourmoneyadviser@nytimes.com
URL: http://www.nytimes.com/2017/01/27/your-money/sign-up-for-health-care-coverage-absolutely-experts-say.html
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GRAPHIC: PHOTO: A free clinic last month in Milton, Fla. The deadline to sign up for 2017 insurance under the Affordable Care Act is on Tuesday. (PHOTOGRAPH BY SPENCER PLATT/GETTY IMAGES)
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September 29, 2014 Monday
Can a Company Reimburse Employees Who Buy Their Own Health Insurance? Maybe
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 622 words
HIGHLIGHT: Employers may not know whether such a post-tax arrangement is legal until they try it.
Two weeks ago, in a post answering questions about how the Affordable Care Act affects small businesses, we returned to the beguiling matter of whether business owners can use tax-free dollars to reimburse employees who buy their own insurance.
We had previously reported on a product from Zane Benefits that promises exactly that, and in this most recent post we reiterated what seems to be conventional wisdom about the still-evolving rules: Most people do not believe the Internal Revenue Service considers such schemes legal. We added, however, that post-tax reimbursements are "perfectly legal."
Then we heard from Sarah L. Fowles, an employee-benefits lawyer in Milwaukee, who wrote, essentially, Not so fast!
"Reimbursing employees for their individual insurance premiums on a post-tax basis can still create a 'group health plan,' according to my informal discussions with the Department of Labor," she wrote. The Affordable Care Act establishes new requirements for group health plans meant to limit their stinginess. For example, a group health plan may no longer cap payouts for what the law calls essential health benefits.
Government regulators, however, have suggested that premium reimbursement is a de facto limit on benefits, so a group health plan that only reimburses employees for the premiums they buy violates the law. "The A.C.A. rules at issue apply to 'group health plans,' not just pretax group health plans," Ms. Fowles wrote.
In Ms. Fowles's view, the only way an employer can reimburse employees legally for their insurance premiums is to give all employees a raise that is not contingent on whether the worker actually buys insurance with it. The Internal Revenue Service's approach, she said, "requires employee choice about how an employee uses his or her extra after-tax amounts - the employee must be able to use the after-tax amounts for health insurance or whatever else he or she wants." (The I.R.S. and the Labor Department are jointly writing the rules to carry out this aspect of the Affordable Care Act.)
Seth T. Perretta, a health and tax lawyer with the Groom Law Group in Washington, agreed that a straight dollar-for-dollar reimbursement of health insurance would amount to a group health plan and thus violate the Affordable Care Act's prohibition on annual limits. Moreover, he said, "I'm not sure you have a basis to treat those amounts as taxable income, because the Internal Revenue Code says that an employee's gross income does not include amounts paid by an employer for their employees' medical expenses."
But, he continued, between a dollar-for-dollar reimbursement, which existing government guidance would seem to deem illegal, and a pay raise completely dissociated from health insurance premiums, which would clearly be legal, lies considerable gray area. For example, Mr. Perretta said, "I think there is an argument that if I merely require you - as a condition of eligibility for the additional wages - to enroll in some medical coverage, but the amount I pay in taxable wages to you is unrelated to the cost of that coverage," that would not be a group health plan subject to the health law's strictures.
Mr. Perretta conceded that he was not sure if the I.R.S. and Labor Department would agree with this point, but, he said, "they have not taken as strong of a position" as Ms. Fowles seems to suggest. And given what he said was unhappiness in Congress that the I.R.S. had prohibited tax-free health insurance reimbursement, "I think the regulators would be unlikely to raise issues" with an after-tax arrangement vaguely contingent on a worker's purchasing health insurance.
In other words: Employers may not know whether such a post-tax arrangement is legal until they try it.
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October 30, 2016 Sunday
Late Edition - Final
Increase in Health Act Premiums May Affect the Voting in Arizona
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 1399 words
PHOENIX -- Arizona was shaping up to be one of the more unlikely battlegrounds of the 2016 campaign when a political bombshell appeared to explode last week: The Obama administration revealed that the cost of midlevel plans on the Affordable Care Act's health insurance marketplace here would increase next year by 116 percent on average.
Senator John McCain, running for re-election against the headwind of Donald J. Trump, took the bad news as a gift, highlighting it in a new television ad that begins, ''When you open up your health insurance bill and find your premiums are doubling, remember that McCain strongly opposes Obamacare.'' Other Republican candidates here also seized on the rate increases, counting on the issue to buoy them with Election Day imminent and Mr. Trump losing ground in the Republican-dominated state.
But as with everything related to the Affordable Care Act, it is complicated. The rate increases had been predicted for months as insurer after insurer announced plans to drop out of the marketplace here. Very few Arizonans are directly affected. Voting has already begun, and the political environment has been largely fixed for months, defined by deep divisions over immigration, Hillary Clinton's emails and Mr. Trump's fitness for office.
The rate increases, in fact, are unlikely to be a deciding factor.
Leslie Rycroft of Scottsdale, who works in human resources, is paying $1,100 a month this year for a United Healthcare plan that has a $13,000 deductible for her family of four. Their income was a little too high to qualify for a subsidy, she said. When she looked at her options on HealthCare.gov last week, she said she was ''absolutely horrified'' to see only one insurer, Health Net, offering plans that started at $2,200 a month. ''It's beyond ridiculous,'' she said. ''All of a sudden you are paying $26,000 a year,'' Ms. Rycroft said, ''just for catastrophic health insurance.''
Still, Ms. Rycroft, 59, said she had already cast her vote for Hillary Clinton. A registered Republican, she finds Mr. Trump ''abhorrent,'' she said. She did split her ticket and voted for Mr. McCain instead of his Democratic opponent, Representative Ann Kirkpatrick, because of his national security experience, she said.
Shortly after Ms. Rycroft learned about her rate increase, she got a reprieve in the form of a job offer. Her new job will provide insurance starting in January.
On Monday, the Obama administration confirmed what many Arizonans had already suspected, publishing premiums for policies offered under the Affordable Care Act that revealed that Arizona faces the biggest average rate increase in the country. The news was even worse in Phoenix, the nation's sixth-largest city, where the price of a midlevel plan will increase by 145 percent on average.
Insurers rushed into the Phoenix market in the early years of the Affordable Care Act, offering some of the lowest prices in the country. But many younger, healthier people failed to enroll, and sick people flocked to the Arizona exchange, taking advantage of the law's prohibition on denying coverage for pre-existing medical conditions. It now appears that many insurers severely underpriced their premiums, and they are now making up for that error by either jacking up rates or simply leaving the marketplace.
The fourth open enrollment for Affordable Care Act plans starts Tuesday, and in Phoenix and its suburbs, only one insurer, Health Net, a subsidiary of Centene, is offering plans for next year, compared with eight this year.
Many customers, particularly those with lower incomes, will not be affected by the price increase; the subsidies that the law provides to help pay premiums will cover most or all of it. Seventy-four percent of Arizonans with marketplace plans got subsidies this year, and the percentage is expected to grow next year.
But for those whose incomes are too high to qualify for premium subsidies -- people who earn more than 400 percent of the federal poverty level, or $97,200 for a family of four -- the price increases will be excruciating.
''When things flare up around Obamacare, it tends to motivate Republicans,'' said Glenn Hamer, president and chief executive of the Arizona Chamber of Commerce and Industry. ''I would say with 100 percent certainty that this is going to help Republicans. How much? Who knows?''
Most Arizonans have health insurance through their jobs. About 180,000, or less than 3 percent of the population, had insurance through the Affordable Care Act marketplace as of March, the most recent data the federal government has released. Others -- it is unclear how many, because the state says it does not keep track -- buy essentially the same plans outside HealthCare.gov, going directly to insurers. They cannot receive subsidies but will be affected by the rate increases.
Dante Fierros of Tempe, who owns a small manufacturing business, blames the health law for the rising cost of insuring his 30 employees, although the connection, if any, is unclear. Like many of the law's opponents, he also considers it an example of government overreach. The turbulence in the Affordable Care Act marketplace here only solidified his support for Mr. Trump. ''I think it will help him,'' Mr. Fierros said of the rate hikes. ''It's kind of late, though.''
Hostility toward the health law is considerable here, but not overwhelming. A poll conducted this month by The Arizona Republic, the Morrison Institute for Public Policy and Cronkite News found that voters here remain divided on the Affordable Care Act, with 53 percent opposing and 40 percent supporting it. That is somewhat more negative than the national view, according to the latest Kaiser Family Foundation tracking poll, which found 45 percent of Americans opposing the law and 45 percent supporting it.
Mr. McCain has made the health law's troubles a centerpiece of his re-election campaign, attacking it for months now in ads and on the stump. It is a particularly potent issue with the Republican base, whose support he has sought to solidify after many voted for his primary opponent. He has hammered Ms. Kirkpatrick for voting for the law in 2010 and calling it her ''proudest moment'' in Congress, a claim she stood by in a debate on Oct. 10. Like Mrs. Clinton, Ms. Kirkpatrick -- whom polls show trailing far behind Mr. McCain, a four-term incumbent and his party's presidential nominee in 2008 -- says the law needs to be fixed, not repealed.
Allen Gjersvig, who helps oversee Affordable Care Act enrollment efforts around the state, said he had been running the numbers and finding many plan holders might even spend less on premiums next year because subsidies were jumping along with rates.
''What the headline or social media or your neighbor says may not be your reality,'' said Mr. Gjersvig, the director of navigator and enrollment services for the Arizona Association of Community Health Centers.
He added, however, that people in Maricopa County, which includes Phoenix, Scottsdale and Tempe, would have a narrower network of hospitals to choose from next year. The same goes for Pima County, home of Tucson, where Blue Cross Blue Shield of Arizona is selling only ''catastrophic'' plans through the marketplace next year, and only to people younger than 30. For everyone else, the only insurer will be Health Net.
Kathy Hornbach, 60, a breast cancer survivor in the Tucson area, was certain the rate increases and insurer exits would not affect her, as she receives a generous subsidy and had heard Blue Cross Blue Shield, her current insurer, was staying in the marketplace in her county. Then she looked on HealthCare.gov.
''Disaster!'' she wrote in an email, after learning Blue Cross would no longer cover people in her age group and her only option was a plan from Health Net. ''I know nothing about this company, they know nothing about this market, I have no idea how restricted their plan is, and there is no information available for me to review.''
On a brighter note, her monthly premium, now $195 after her subsidy, will drop to $79 while her subsidy more than doubles. Ms. Hornbach, while shaken, is a self-described liberal Democrat who will still vote for Mrs. Clinton.
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URL: http://www.nytimes.com/2016/10/30/us/politics/affordable-health-care-premiums-arizona.html
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GRAPHIC: PHOTO: Kathy Hornbach, 60, a breast cancer survivor in Tucson, learned Blue Cross would no longer cover people in her age group. (PHOTOGRAPH BY CAITLIN O'HARA FOR THE NEW YORK TIMES)
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July 3, 2015 Friday
Hillary Clinton Warns That a Republican President Would Repeal the Health Law
BYLINE: MAGGIE HABERMAN
SECTION: US; politics
LENGTH: 696 words
HIGHLIGHT: Hillary Rodham Clinton warned that a Republican president would repeal the Affordable Care Act, and she denounced the administration of George W. Bush for “poor management” of the economy that led to the recession.
HANOVER, N.H. - Hillary Rodham Clinton warned on Friday that a Republican president would repeal President Obama's Affordable Care Act, and she denounced the administration of George W. Bush for "poor management" of the economy that led to the recession.
The harsh words from Mrs. Clinton came as she addressed a crowd estimated by her aides at more than 850 in Hanover, the leafy New Hampshire town that is home to Dartmouth College.
The state has long been hospitable to the Clinton family - her husband called himself "the comeback kid" after finishing second in the primary here in 1992, and she won the 2008 primary - but Mrs. Clinton's appearance here came as Bernie Sanders, the Vermont senator, has been surging in polls.
"I will fight hard against what I see as the injustice and unfairness in our society," Mrs. Clinton said, discussing her record and seemingly mindful of Mr. Sanders as she did. "I take a back seat to no one when you look at my record of standing up and fighting for progressive values."
Mrs. Clinton's aides have struggled since before she announced her candidacy with the reality that her sky-high early poll numbers would be almost impossible to sustain. They have sought to diminish the expectations for her, and have sought to avoid chasing distractions.
The Vermont border is just across the Connecticut River from Hanover. Several attendees at Mrs. Clinton's event said they were either from Vermont and were curious, or were supporting Mr. Sanders.
Mrs. Clinton's speech demonstrated the challenge she faces: She must keep a wary eye on Mr. Sanders without attacking him, but she must also seem engaged and rouse her supporters, so attacks on the Republican field on issues like the Affordable Care Act have been her approach.
"I will defend it and I will do everything i can to improve it," Mrs. Clinton said of Mr. Obama's signature health care law, calling it an issue of "fairness and humanity, also of economics" and praising the Supreme Court for recently upholding it.
Republican calls for "repeal, repeal, repeal mean nothing - unless they elect a Republican president," Mrs. Clinton warned, saying ominously, "If the country elects a Republican president, then they will repeal the Affordable Care Act."
Her voice rising at times, Mrs. Clinton called for new gun control laws as she spoke in a state where many residents own guns. And she sounded a note of muted praise for a potential nuclear deal with Iran, while vowing to defend her record on "progressive values" against anyone.
Holding a microphone as she spoke from the stage at The Bema, an amphitheater-style spot near the college campus - where, according to a Clinton aide, the high school graduation of Mrs. Clinton's Vermont-bred campaign manager, Robby Mook, took place - she said that Republican policies had a history of failure.
"Then Democrats have to come in and fix what's broken," she said, noting that at the end of her husband's two terms there was a "surplus that would have paid off the national debt had it not been rudely interrupted by the next administration."
Republicans "just don't know the theory of original sin, because we wouldn't have had to have a recovery if we hadn't had the kind of poor management and bad economic policies that put us into the ditch in the first place," she said to applause.
Mr. Obama, she said, "deserves a lot more credit than he's usually given" for pulling the economy back.
She also pledged to continue discussing gun control, saying, "We have to work very hard to muster the public opinion to convince Congress" to support universal background checks for gun buyers.
"I think it is the height of irresponsibility not to talk about it, so I will talk about it," she said.
As for Iran, Mrs. Clinton walked a careful line. She said she supported the Obama administration in its efforts to get a deal to curtail Iran's nuclear capabilities, calling it a "singular step in the right direction," but warned that such a deal would not change the fact that Iran was an "existential threat to Israel."
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November 29, 2016 Tuesday 00:00 EST
Tom Price, H.H.S. Nominee, Drafted Remake of Health Law
BYLINE: ROBERT PEAR
SECTION: US
LENGTH: 1409 words
HIGHLIGHT: Mr. Price's bill, the Empowering Patients First Act, would weaken many consumer protections in the Affordable Care Act, President Obama's signature domestic achievement.
WASHINGTON - In choosing Representative Tom Price of Georgia to be his health secretary, President-elect Donald J. Trump has signaled an undiminished determination to repeal President Obama's signature domestic achievement, the Affordable Care Act, and replace it with a health law that would be far less comprehensive.
And Mr. Trump is handing Republicans and their base voters what they have clamored for since the Affordable Care Act became law in 2010 - a powerful force to reverse course.
Republicans were pleased.
"I can tell you where we're going to start: with a process to repeal and replace Obamacare," Senator Mitch McConnell of Kentucky, the majority leader, said Tuesday.
Mr. Price, an orthopedic surgeon from Atlanta's affluent northern suburbs, was one of the first lawmakers to draft a full replacement for the Affordable Care Act. His proposal would take health care in a fundamentally different direction, away from mandated coverage and care and toward a free-market approach, with fewer consumer protections and more freedoms for doctors.
"The president-elect has made it very clear: He wants the Congress, when they convene in early January, to take up the task of repealing and replacing Obamacare first," Vice President-elect Mike Pence said Tuesday on Fox News. He described Mr. Price as "someone who literally, for the last half a dozen years, has been in the forefront of efforts, not only to repeal Obamacare, but put forward common sense, free-market solutions that will lower the cost of health insurance, without growing the size of government."
Some 20 million uninsured people have gained coverage under the Affordable Care Act, reducing the nation's uninsured rate to 8.6 percent, the lowest on record, the Obama administration says. The Congressional Budget Office has not estimated the cost of Mr. Price's legislation or its effects on coverage, but opponents say the human cost would be steep.
The Price bill, the Empowering Patients First Act, would weaken many protections for consumers in the Affordable Care Act. The law, for example, prohibits insurers from denying coverage or charging higher rates because of a person's pre-existing medical conditions. Under the bill, this type of protection would be available to people who have maintained coverage in the past - for example, people moving to the individual market from an employer's health plan.
The federal requirement for most Americans to have health insurance or pay a tax penalty would be eliminated, as would the requirement for larger employers to offer coverage. Billions of dollars that 31 states expect to receive for expanding Medicaid eligibility would also disappear.
Instead, Mr. Price would offer tax credits for the purchase of individual and family health insurance policies. The credits would increase as people grow older and are likely to need more medical care. He would use other tax breaks to coax more people into contributing to health savings accounts that could be used to help pay medical expenses. Such accounts are championed by conservatives as a way to slow the growth of health costs.
The bill would make it easier for doctors to defend themselves against medical malpractice lawsuits. Patients would have a heavier burden of proof if doctors could show that they followed "clinical guidelines" for the treatment of medical conditions.
And under the legislation, it would be easier for doctors to enter into private contracts with Medicare beneficiaries. Such contracts allow physicians to opt out of Medicare's strictures and charge more than the amounts normally allowed.
The bill would eliminate the federal health insurance exchange, through which millions of people have obtained subsidies for the purchase of insurance coverage. States could contract with private entities to set up websites that resemble HealthCare.gov, but only to provide information on insurance plans' prices and benefits and their networks of doctors and hospitals. The new websites could not directly enroll people in private plans or in Medicaid.
From his days as a Georgia state senator, Mr. Price, now 62, has been a voice for doctors, and if confirmed by the Senate, he could use his post as health secretary to protect fellow physicians in myriad ways. As health secretary, he would have real power, not only through his influence with Congress but also through the regulatory levers of the Centers for Medicare and Medicaid Services, a part of the Department of Health and Human Services.
His bill says that doctors would generally be "exempt from the federal antitrust laws" when they engage in contract negotiations with health insurance plans over the terms of their service. In many cases over the years, the federal government has accused doctors of violating antitrust laws in their dealings with insurers.
The legislation would also offer federal grants to states for "high-risk pools" to subsidize insurance for people who might otherwise have difficulty finding coverage in the open market because of "the existence or history of a medical condition."
Such pools have not worked so well in the past, and Douglas W. Elmendorf, a former director of the Congressional Budget Office who is now dean of the Kennedy School of Government at Harvard, expressed doubts about their effectiveness.
"High-risk pools sound clever," Mr. Elmendorf said Tuesday, "but why would isolating the sickest people be expected to reduce the cost of insuring them?"
Mr. Price's bill would also allow insurers licensed in one state to sell policies to residents of other states, a change that Mr. Trump often advocated in the campaign.
Beyond the possible loss of coverage gains, Mr. Price's bill would be controversial for other reasons. One particularly contentious provision would limit the amount of tax-free coverage that workers could receive from their employers. The limits would be set at $8,000 for coverage of an individual employee and $20,000 for family coverage, with adjustments for inflation in later years.
Democrats are preparing for a fight. Senator Chuck Schumer of New York, the next minority leader, called Mr. Price "far out of the mainstream of what Americans want when it comes to Medicare, the Affordable Care Act and Planned Parenthood."
Mr. Trump said Tuesday that he had chosen Seema Verma, a health policy expert in Indiana, to be administrator of the Centers for Medicare and Medicaid Services. Working in state government and then as president of a consulting company, she helped Indiana expand Medicaid eligibility under the Affordable Care Act, with conservative policies that emphasized "personal responsibility."
Ms. Verma worked closely with Mr. Pence, the Indiana governor, who honored her this year with a Sagamore of the Wabash award, for Hoosiers who have made outstanding contributions to the state. She has won praise from health care providers and state legislators of both parties in Indiana, and has provided technical assistance to Medicaid officials in other states.
Mr. Price, who is chairman of the House Budget Committee and a member of the powerful Ways and Means Committee, has received generous campaign contributions from health care and related industries. In the latest cycle, he received $396,000 from health professionals, $181,900 from people who work for drug and other health-product companies, and more than $157,000 from people in the insurance business, according to the Center for Responsive Politics, an independent group that tracks money in politics.
In his campaign manifesto, Mr. Trump said Congress should give each state a lump sum of federal money - a block grant - for Medicaid, the program for lower-income people. Regardless of whether they can achieve that goal, Mr. Price and Ms. Verma would almost surely make it easier for states to obtain Medicaid waivers, the vehicle for a wide range of state innovations and experiments, which could include new eligibility rules and cost-sharing requirements.
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PHOTO: Representative Tom Price, Donald J. Trump's choice for health secretary, offered a full replacement for the Affordable Care Act. (PHOTOGRAPH BY DREW ANGERER FOR THE NEW YORK TIMES) (A15)
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July 5, 2016 Tuesday 00:00 EST
Court Strikes Down Obama Health Care Rule on Insurance Standards
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 863 words
HIGHLIGHT: A federal appeals court said the Obama administration must allow the sale of "fixed indemnity" insurance, generally a less comprehensive policy.
WASHINGTON - A federal appeals court has ruled that consumers must be allowed to buy certain types of health insurance that do not meet the stringent standards of the Affordable Care Act, deciding that the administration had gone beyond the terms of federal law.
The court struck down a rule issued by the Obama administration that barred the sale of such insurance as a separate stand-alone product.
"Disagreeing with Congress's expressly codified policy choices isn't a luxury administrative agencies enjoy," the United States Court of Appeals for the District of Columbia Circuit said on Friday in a decision that criticized "administrative overreach" by the Department of Health and Human Services.
At issue is a type of insurance that pays consumers a fixed dollar amount, such as $500 a day for hospital care or $50 for a doctor's visit, regardless of how much is actually owed to the provider.
Such "fixed indemnity" insurance is normally less comprehensive and less expensive than the "minimum essential coverage" required by the Affordable Care Act. Under the rule, issued by the Obama administration in 2014, fixed indemnity policies could be sold only to people who already have the more comprehensive coverage that meets detailed federal standards.
State officials and insurers estimate that as many as four million people might have fixed indemnity policies without major medical coverage.
The Obama administration gave several reasons for cracking down on fixed indemnity insurance. It is "an inadequate substitute for major medical coverage" because "it does not provide protection against major medical expenses," the administration said. Moreover, it said, consumers may be confused and may buy fixed indemnity insurance in "the mistaken belief that it provides comprehensive coverage" - a concern also voiced by consumer groups.
In adopting the final rule in 2014, the Obama administration said that allowing people to buy free-standing fixed indemnity insurance would undermine the goal of "maximizing the number of individuals who have comprehensive, major medical coverage."
Since 1996, fixed indemnity insurance has generally been exempt from federal insurance standards, and the Affordable Care Act did not change that, nor did Congress "give even the slightest indication" that it meant to alter the exemption, the appeals court said.
But, the court said, the administration "effectively eliminated stand-alone fixed indemnity plans altogether," by tacking "additional criteria" onto the 1996 law.
The ruling in the case, Central United Life Insurance v. Burwell, was issued by a panel composed of Judges Janice Rogers Brown, Patricia A. Millett and Douglas H. Ginsburg.
Fixed indemnity insurance differs from major medical coverage in many ways. It does not have to provide the "essential health benefits" required by the Affordable Care Act, nor does it have to pay any specific percentage of medical costs. Some fixed indemnity policies provide coverage only for specified diseases, like cancer. In general, consumers have fewer protections.
Under the rule issued by the Obama administration, fixed indemnity insurance would be allowed only as a supplement to major medical coverage that complied with the 2010 health care law. People buying the more limited coverage would have to attest, in their applications, that they already had "minimum essential coverage."
The plaintiffs in the case, who sell fixed indemnity insurance, said the federal rule would essentially destroy the market for such products.
"Even after the Affordable Care Act, lower-income consumers may not be able to afford major medical coverage," said Quin M. Sorenson, a lawyer at Sidley Austin who represented the plaintiffs. In states that have not expanded Medicaid eligibility, he said, three million people fall into a coverage gap: They make too much to qualify for Medicaid, but not enough to qualify for subsidies in the public insurance marketplace, and they cannot afford major medical coverage on their own.
For some of them, he said, fixed indemnity insurance plans may be a valuable option.
Under the Affordable Care Act, people who go without major medical coverage may be subject to tax penalties. In a friend-of-the-court brief, Wisconsin and 10 other states said that some consumers had found they could save money by buying fixed indemnity insurance and paying the tax penalty.
"Fixed indemnity insurance is a rational choice for these individuals because it provides meaningful access to the health care system," the states' brief said.
The appeals court upheld an earlier decision by Judge Royce C. Lamberth of Federal District Court, who said the Obama administration's rule "has no basis in the statutory text it purports to interpret and plainly exceeds the scope of the statute."
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June 6, 2015 Saturday
Late Edition - Final
Short-Term Health Insurance Attracts Many Despite Drawbacks
BYLINE: By ANN CARRNS
SECTION: Section B; Column 0; Business/Financial Desk; YOUR MONEY ADVISER; Pg. 5
LENGTH: 814 words
TEMPORARY, bare-bones insurance plans that don't meet the requirements of the Affordable Care Act are still attracting consumers, online insurance brokers report. But health experts caution consumers to be wary of the plans.
Ehealth, a publicly traded online health insurance broker, said on Wednesday that the number of applicants for the short-term plans on its website more than doubled in 2014, to 140,000 people. (EHealth has struggled to compete in the sale of comprehensive health plans since the Affordable Care Act made policies with premium help available on government exchanges, according to an analysis this week by Kaiser Health News.) Short-term plans are also known as ''gap'' plans because they were originally intended to fill gaps in coverage, as when people were between jobs.
Whether an increase in short-term policies is a national trend is unclear. The policies tend to be lightly regulated, and some insurers don't disclose sales of specific types of plans, so data is scant. But other web brokers, like GoHealth, also say they have seen increased interest in the plans.
Short-term policies, which offer primarily catastrophic coverage for major injuries, are available outside the Affordable Care Act's open enrollment period, but come with many caveats. The plans are available in one-month increments of up to 11 or 12 months, although some plans have shorter maximum coverage periods, like three to six months. They generally require medical underwriting, meaning that applicants can be declined based on their health history -- something that cannot be done with Affordable Care Act-compliant plans, a crucial protection. (EHealth said 12 percent of its short-term applications were declined in 2014, mainly for medical reasons.)
Plus, short-term plans are ''nonrenewable,'' which means that once they expire you must reapply for new coverage, and submit to medical underwriting again, said Karen Pollitz, a health policy expert at the Kaiser Family Foundation.
Once you make a significant claim under such a plan, insurers are unlikely to offer you another one, Ms. Pollitz said. Or they may exclude benefits for care related to your previous claim, before issuing you another policy. Some insurers may also conduct ''post claim'' underwriting, which means that if you make a claim, the insurer can review your past health history to see if the condition predated your policy. If it finds that it did, your claim may be denied.
''It's tenuous protection at best,'' she said.
The plans generally carry lower premiums because benefits are limited. But plan deductibles -- the amount you must pay out of pocket before the plan pays -- can still be hefty. The average premium for individual short-term plans sold on eHealth was $110 last year, while the average deductible was $3,589. ''The premiums are low for a reason,'' Ms. Pollitz said.
So, why would someone buy such a plan? Nate Purpura, a spokesman for eHealth, said some buyers were people who missed the open enrollment period for Affordable Care Act plans but then decided they wanted some coverage. Yet they lacked a qualifying event, like a job loss, that would allow them to buy on the government exchanges after the enrollment period. Another group of purchasers includes those who didn't qualify for the health law's premium subsidy, but also don't qualify for coverage under Medicaid, he said. More than half of eHealth's short-term applicants were 18 to 34 years old.
Here are some questions and answers about short-term health insurance:
â- If I buy a short-term policy, will I avoid the Affordable Care Act's penalty for not having coverage?
No. Short-term policies don't meet the law's requirement for ''minimum essential'' coverage. So even if you enroll in a short-term plan, you'll probably still have to pay a penalty. The penalty for a single person for not having coverage in 2015 is $325 or 2 percent of income.
â- What else should I know about short-term insurance policies?
They typically don't cover maternity care, and they may not cover prescription drugs.
â- When is the next open enrollment period for health insurance under the Affordable Care Act?
The next open enrollment is scheduled to begin on Nov. 1 and end Jan. 31. There are potential changes afoot before then, however. The Supreme Court is set to rule this month on a challenge to the Affordable Care Act that could invalidate health insurance subsidies for millions of people. The court's decision may roil the government health insurance exchanges and the insurance market over all, so it's something that those with exchange plans should monitor closely.
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URL: http://www.nytimes.com/2015/06/06/your-money/short-term-health-insurance-attracts-many-despite-drawbacks.html
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July 2, 2013 Tuesday
Putting Off the Employer Mandate
BYLINE: JARED BERNSTEIN
SECTION: BUSINESS; economy
LENGTH: 734 words
HIGHLIGHT: Although the White House is delaying a provision requiring employers to offer health coverage or pay a penalty, the key aspects of the Affordable Care Act should be little affected, an economist writes.
Jared Bernstein is a senior fellow at the Center on Budget and Policy Priorities in Washington and a former chief economist to Vice President Joseph R. Biden Jr.
Well, I didn't see that coming. The Obama administration announced Tuesday afternoon that it was going to delay an important part of the Affordable Care Act for one year. The rule requiring employers with at least 50 full-time workers to provide them with coverage or pay a penalty (also known as the employer mandate) will now be enforced starting in 2015, not 2014 as originally planned.
Here's a very brief look at why, what, and what it means.
A Treasury official published a blog post explaining that officials decided to give businesses more time to comply with the reporting requirements. As The Times reported:
"We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively," Mark J. Mazur, an assistant Treasury secretary, wrote on the department's Web site in disclosing the delay. "We recognize that the vast majority of businesses that will need to do this reporting already provide health insurance to their workers, and we want to make sure it is easy for others to do so."
Though the mandate will ultimately affect only a few employers, it is actually an important piece of the law's architecture. Without it, employers who currently provide coverage to their workers could drop the coverage and send their workers over to the state health care exchanges. And since some of those employees would be eligible for subsidies to help defray the cost, the employer would be shifting what is now a private cost over to the government.
The penalty for such actions was supposed to kick in next year; now they'll kick in the year after next. The government needs a bunch of information from businesses to determine if the penalty is warranted, and the White House is now saying that putting that reporting process in place is going to take longer than expected.
How will this affect coverage? Hard to see it having much impact at all. The important coverage aspects of the Affordable Care Act - the Medicaid expansion and the state health care exchanges - are still scheduled to be up and running by Oct. 1, the beginning of the fiscal year (of course, not every state has accepted the Medicaid part). And the requirement to have health insurance or pay a penalty - the individual mandate - will still take effect in 2014.
And a vast majority of employers with at least 50 full-time workers - about 95 percent - already offer coverage to the workers. With the exchanges going up, there's a chance some employers could try to pull off the cost shift noted above, but the mandate will be in place by 2015, so we're unlikely to see much of that.
At least one report suggests a budgetary cost from the delay, since the revenues from penalties would flow to the Treasury Department. But a colleague who tracks this stuff very closely tells me that while the Congressional Budget Office earlier this year scored this part of the bill as providing $5 billion to the Treasury next year, its most recent score dropped that to zero. The budget office appears to have wisely assumed it was already going to take a while to get this part of the system up.
So, no budget cost, little impact on coverage. Is this delay just not a big deal?
Um ... this is Washington, folks, and we're talking Obamacare. There will be much hay made of this delay in coming days. Conservatives will argue that this confirms that the law is unmanageable - which is a bit rich, since many of them have been trying to kill it, block it, and stop it in its tracks. (Speaker John Boehner's press secretary, Brendan Buck, on Twitter: "Obamacare. Such a train wreck.") Liberals may argue that the administration is caving to business, which just wants to put off the paperwork for a year.
I think it's an unfortunate delay of an important but relatively small piece of the bill, more growing pains of the type I'm sure Medicare had when it got going than anything existential. But that's not how it will play in the hurly-burly of the next few days of Washington politics.
Confusing the Public on the Affordable Care Act
'Premium Shock' and 'Premium Joy' Under the Affordable Care Act
The New Subsidy for Layoffs
Affordable Care Act Could Be Good for Entrepreneurship
Massachusetts Employees Will Keep Their Health Plans
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(First Draft)
February 12, 2015 Thursday
Obama, a Selfie Stick and the Affordable Care Act
BYLINE: FIRST DRAFT
SECTION: US; politics
LENGTH: 80 words
HIGHLIGHT: President Obama has made it abundantly clear that he will do almost anything to make sure the Affordable Care Act is a success.
President Obama has made it abundantly clear that he will do almost anything to make sure the Affordable Care Act is a success.
The latest example came on Thursday, with the release of a video produced by BuzzFeed showing him playing with a "selfie stick," admiring himself in sunglasses, and practicing his jump shot alone in his office. Without a ball.
Why would the commander in chief go through such humiliation? To remind people that they need to sign up for health insurance.
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January 13, 2017 Friday 00:00 EST
House Clears Path for Repeal of Health Law
BYLINE: THOMAS KAPLAN and ROBERT PEAR
SECTION: US; politics
LENGTH: 1225 words
HIGHLIGHT: The vote on a budget blueprint sets Congress on a course to fulfill a Republican promise to rescind the Affordable Care Act, President Obama's signature domestic achievement.
WASHINGTON - The House cleared the way on Friday for speedy action to repeal the Affordable Care Act, putting Congress on track to undo the most significant health care law in a half-century.
With a near party-line vote of 227 to 198, the House overcame the opposition of Democrats and the anxieties of some Republicans to approve a budget blueprint that allows Republicans to end major provisions of President Obama's health care law without the threat of a Democratic filibuster in the Senate.
President-elect Donald J. Trump, Speaker Paul D. Ryan and other Republican leaders now face a much bigger challenge: devising their own plan to ensure broad access to health care and coverage while controlling costs. While their party is far from a consensus on how to replace the health care law - under which more than 20 million Americans have gained health insurance - they will need votes from Democrats in the Senate to enact a robust replacement plan.
Republicans have argued that Americans have been crushed by soaring premiums and other unintended effects of the law, which was adopted without any Republican votes.
"This is a critical first step toward delivering relief to Americans who are struggling under this law," Mr. Ryan said, adding, "This experiment has failed."
Democrats warned that repeal of the health law would cause hardship for millions of Americans and create chaos in insurance markets and in the health care system, which accounts for about 18 percent of the nation's economy.
"If we go down this path, we won't have repeal and replace," said Representative John Yarmuth of Kentucky, the senior Democrat on the House Budget Committee. "What we'll have is repeal and repent because we're going to owe a huge apology to the American people for the damage that we cause."
Representative Suzan DelBene of Washington, a Democrat, said, "There's still no plan for what comes next, threatening massive disruption to the entire health care system."
In the days before the House vote, some conservative Republicans, as well as moderates, expressed discomfort about signing off on the budget blueprint without having a clearer picture of how and when Republican leaders planned to replace the health care law. Nine House Republicans ended up voting against the budget measure on Friday. No Democrats voted for it.
The Senate approved the same measure early Thursday by a vote of 51 to 48. The House and Senate votes this week - essentially procedural steps - represented the first of several moves that Republicans plan to make as they work to unwind the health care law.
In the coming weeks, they say, they will try to devise a replacement, working closely with Mr. Trump and his choice to lead the Department of Health and Human Services, Representative Tom Price of Georgia.
Four committees - two in the Senate, two in the House - will write language repealing major provisions of the 2010 health law. The resulting legislation can be passed with simple majorities in both chambers, and will be immune to a Democratic filibuster in the Senate.
Then, Republicans say, they will pass one or more free-standing bills to replace selected provisions of the Affordable Care Act. In the Senate, where Republicans hold 52 seats, they will need help from Democrats to reach the 60 votes necessary to approve such legislation.
Mr. Trump voiced support this week for repealing and replacing the health care law "essentially simultaneously," though it remained to be seen if Republicans in the Senate can win enough Democratic support to adopt a replacement for the existing health care law, given the need to reach 60 votes.
In the House debate on Friday, Republicans and Democrats offered wildly differing views of health care and health insurance.
Representative Jason Lewis of Minnesota, a first-term Republican, said he had firsthand experience with the Affordable Care Act.
"Minnesotans have seen their health insurance choices shrink while their premiums, co-pays and deductibles skyrocket," Mr. Lewis said. "I should know. For the last, in fact, over five years, I've been in the individual market, and my own insurance premiums have nearly tripled, and I've gone through three insurers. Minnesotans have seen a 50 to 67 percent increase in the premium cost this year alone."
The House Democratic leader, Representative Nancy Pelosi of California, who helped engineer passage of the health law, defended it on Friday, saying that every American benefited.
"The Republicans are feeding their ideological obsession with repealing the A.C.A. and dismantling the health and economic security of hard-working families," Ms. Pelosi said. For six years, she said, Republicans have had the chance to put forth an alternative, but "we've seen nothing."
Echoing their colleagues in the Senate, Democrats asked how Republicans planned to go about replacing the Affordable Care Act - a complex, arduous task, as Democrats know from their own experience developing and passing the health law in the first place.
"When you put pen to paper, all hell is going to break loose on your side," said Representative Peter Welch, Democrat of Vermont.
Democrats also tried to draw attention to what they said would be the devastating consequences of repealing the health care law.
Over and over, after a Republican member spoke out against the law, Mr. Yarmuth offered several data points specific to the member's home state, including how many people would lose their health coverage.
Republicans, though, were eager to deliver on a central campaign promise. "The public has rendered judgment on this health care law," said Representative John Shimkus of Illinois.
The differing views among House members on Friday foreshadowed the acrimony that is all but certain in the weeks to come, as Republicans press ahead with their repeal efforts over Democrats' strenuous objections.
So far, lawmakers have shown some creativity in trying to explain the wisdom - or lack of wisdom - in moving forward with a repeal.
On Friday, Representative Drew Ferguson of Georgia, a freshman Republican, likened the health care law to a goat that had been let loose in a person's home.
"Now for six years, that goat has been messing in and destroying my house," he said. "I want to renovate my house, but before I can, I have to get the goat out of the house before it does any more damage. It makes no sense to start fixing up my house until we get the goat out."
Voting for the measure on Friday, Mr. Ferguson said, would get rid of the goat.
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PHOTOS: Representative Trey Gowdy and other House Republicans voted on Friday on a blueprint toward repeal of the Affordable Care Act. (A1); Representative Kevin McCarthy of California, above, the majority leader, and other House Republicans on Friday made steps toward a repeal of the Affordable Care Act. Representative Nancy Pelosi of California, left, defended the 2010 health care law. (PHOTOGRAPHS BY AL DRAGO/THE NEW YORK TIMES) (A12)
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(Opinionator)
June 23, 2012 Saturday
Money or Your Life
BYLINE: THERESA BROWN
SECTION: OPINION
LENGTH: 857 words
HIGHLIGHT: Health insurance isn't just about costs. It's about being able to afford to live.
He was one of those salt-of-the-earth guys from the rural part of Pennsylvania. Middle-aged, married with adult kids, he'd worked his whole life running his own small business, a local restaurant that he jokingly called a bordello. His wife worked, too, and she had health insurance, but he wasn't on her policy. Maybe he couldn't afford it, or he was saving money by playing the odds. After all, he'd always been healthy. And then one day he had leukemia.
I was his nurse, and he surprised me one afternoon by bringing up "death panels." Usually I avoid having political conversations in the hospital, but he was preoccupied with something that wasn't real. I didn't want him worrying about a chimera when he was adjusting to a diagnosis of cancer and an inpatient hospital stay that would last six weeks or more.
I told him there was no such thing as death panels.
"Really?" he said, in his raspy voice. "Because I hoped there were."
Since he lacked insurance, he feared treatment would bankrupt his family. Trading his life for their livelihood wasn't an exchange he could make. A death panel, he reasoned, would spare him that cruel choice.
This was not suicidal ideation, but the worries of a kind and caring man. Hospitals are filled with people like him, patients who will need thousands of dollars of medical care just to have a chance at staying alive. At the top of the list are those with a fatal cancer. But there are many other less obvious ones: a patient who got kidney failure from strep throat, a healthy 22-year-old who needed a stay in the intensive-care unit to survive the H1N1 virus, a flight attendant far from home and desperately short of breath because of a blood clot in the lungs.
As a result of the 1986 Emergency Medical Treatment and Labor Act, patients needing immediate care cannot be turned away from an emergency department because of an inability to pay. But who picks up the cost of that visit and any later care that's required? Either uninsured patients get huge bills from the hospital, or the rest of us pay for their care indirectly, through higher insurance premiums and increased out-of-pocket costs and deductibles.
The problem is, this robbing-Peter-to-pay-Paul system is quickly becoming economically unsustainable. The uninsured are not paying into the system up front, but one way or another the costs of their care are still being covered.
To address this cost-benefit disparity, the Affordable Care Act requires all Americans to buy health insurance - the idea being that if most of us pay regular insurance premiums, then we as a nation will have enough money in the insurance pot to cover everyone needing care at any one time. Additionally, requirements for getting insurance will become more uniform, and costs will drop.
If the Affordable Care Act is overturned - either legislatively or by the Supreme Court, which might announce a decision on its constitutionality this week - the insured will continue to subsidize the uninsured. Costs of coverage and care will rise, in turn making insurance affordable for fewer and fewer people.
Critics of the Affordable Care Act argue that many Americans neither want nor need health insurance, and that it forces them to pay for coverage against their will. But just as the government collects taxes to pay police officers and firefighters, the individual mandate compels Americans to pay for a service they may not immediately want but could at any time desperately require.
Much of the debate has focused on the role of government in everyday life. I don't discount the value of that question, but my focus is on real needs. I treat patients with $20,000 chemotherapy injections or monthly doses of IV immunotherapy that cost $10,000 a bag. If they don't receive these drugs my patients will die, so to me, the most pressing issue here is compassion. Without change, the patients will resemble the man with leukemia, human beings without insurance terrified that their lives aren't worth what it will cost to save them, all because of a broken but fixable system.
Crowds at conservative rallies have, astoundingly, cheered the idea that uninsured people should, if they become ill or badly hurt, be left for dead. It's easy to imagine such a thing in the heat of a rhetorical moment. But the reality is, I hope, harder to embrace. Because reality means a real person - you, me, someone we know - condemned to a possibly preventable death because, for whatever reason, they don't have insurance.
My patient with leukemia is dead. He got the best care money could buy, but his disease only briefly went into remission and he went home on hospice care. Should he, because he did not buy insurance, have been denied this chance for a cure?
The Affordable Care Act is not the health care solution everyone wants, but when patients wish for death panels as a response to leukemia, something needs to be done, and soon. This plan would help any patient facing a tough diagnosis not view treatment as a choice between his money or his life.
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Control: An Update
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January 17, 2017 Tuesday
Late Edition - Final
Fear Spurs Support for Affordable Care Act as Republicans Work to Repeal It
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 1504 words
WASHINGTON -- President-elect Donald J. Trump and congressional Republicans appear to have accomplished a feat that President Obama, with all the power at his disposal, could not in the past seven years: They have galvanized outspoken support for the Affordable Care Act.
People who benefit from the law are flooding Congress with testimonials. Angry consumers are confronting Republican lawmakers. And Democrats who saw the law as a political liability in recent elections have suddenly found their voice, proudly defending the law now that it is in trouble.
Thousands of people across the country held rallies over the weekend to save the health care law, which Republicans moved last week to repeal with a first but crucial legislative step. A widely circulated video showed Representative Mike Coffman, Republican of Colorado, eluding constituents who had wanted to meet with him to express their concerns on Saturday at a community event in Aurora, Colo. Rallies on Sunday to save the health law drew robust crowds around the country.
''We are here today -- thousands strong in Boston, and at more rallies all across this country -- because we will make our voices heard,'' Senator Elizabeth Warren, Democrat of Massachusetts, told a crowd outside Faneuil Hall in Boston. ''If Republicans try to rip health care out of the hands of millions of Americans, we will fight them every step of the way.''
And progressive groups are planning a two-month cross-country bus tour to fight the repeal effort, starting Tuesday.
With their quick strike on the law in the first days of the new Congress, Republicans had hoped to begin the repeal process before a backlash could develop or opposition could be organized. But congressional Republicans are at risk of losing the message war, especially since they are fighting on two fronts.
On one side, the president-elect has repeatedly lobbed disruptive demands at them, such as his insistence that they prepare a replacement health bill almost immediately. To that, he added a new promise over the weekend: that the Republican version would provide ''insurance for everybody.''
On the other front, Democratic lawmakers have taken to quoting grateful constituents to personalize what can be an arcane legislative fight: Bryce in Seattle; Randy in Rhinelander, Wis.; Nicole in Hockessin, Del.; and many more. The focus of public attention appears to be shifting from the well-documented defects of the health care law to the plaintive pleas of people terrified of losing insurance if the law is repealed.
''I want to thank President Obama from the bottom of my heart because I would be dead if it weren't for him,'' Jeff Jeans, a small-business man from Sedona, Ariz., who described himself as a lifelong Republican, told Speaker Paul D. Ryan on Thursday at a town-hall-style meeting televised on CNN.
Republicans acknowledge their constituents' concerns, but they say supporters of the health law are manufacturing them. Representative Rob Woodall, Republican of Georgia, blamed Democrats for ''amping up anxiety'' with ''fear mongering.''
''The anxiety is real,'' Mr. Woodall said, ''but it's real based on the failures of the president's health care law.''
Republicans will soon face a new challenge: maintaining anger at ''Obamacare'' without Mr. Obama in the White House to stir their passions.
Regardless of its provenance, the law's support has until now received less attention. Appearing on the NBC News program ''Meet the Press'' five days after Mr. Obama signed the Affordable Care Act in 2010, Senator Chuck Schumer, Democrat of New York, predicted that as people learned about the law, ''it's going to become more and more popular.''
Around 20 million Americans have gained coverage through the Affordable Care Act's online insurance marketplaces or through its expansion of Medicaid, and enrollment has continued to grow. About 11.5 million people have signed up for marketplace plans or had their coverage automatically renewed for this year, nearly 300,000 more than at this time last year, the Obama administration said this month.
But the popularity bounce never came. Public opinion remains deeply divided, with the law no more popular today than when it was passed. In December, according to a monthly tracking poll by the Kaiser Family Foundation, 46 percent of Americans had unfavorable views of the law, up from 40 percent in April 2010. The share with favorable views slipped to 43 percent, from 46 percent in April 2010.
''In the short term, the A.C.A. has been a political disaster for President Obama and the Democrats,'' Dr. Ezekiel J. Emanuel, a health policy adviser in the Obama White House from 2009 to 2011, said in a 2014 book.
As Congress took a first step last week toward rolling back Mr. Obama's signature domestic achievement, Mr. Trump celebrated. ''The 'Unaffordable' Care Act will soon be history!'' he said on Twitter.
Some Democrats distanced themselves from the Obama administration after HealthCare.gov crashed on its debut in 2013. More recently, with premiums soaring and insurers defecting from the Affordable Care Act marketplace in many states, Democrats were hard put to defend the law, which was passed without any Republican votes.
But as Mr. Trump and congressional Republicans race to repeal the law, Democrats are taking a more aggressive stance.
Senator Debbie Stabenow, Democrat of Michigan, told the story of Sonja L. Podjan, a 55-year-old blueberry farmer in Watervliet, Mich., who was in pain for several years until she got insurance under the Affordable Care Act, which covered the cost of surgery to repair a severe tear in the meniscus of her right knee.
In an interview, Ms. Podjan said she ''started freaking out'' after the election and sent an email to Ms. Stabenow. She said she was ''flabbergasted'' when she heard back from the senator's office.
Ms. Podjan said that the premium for an insurance policy covering her and her husband was about $1,000 a month, but that they paid just $62 after receiving government subsidies provided under the law.
''I am scared to death we will lose our insurance, and what happens then?'' said Ms. Podjan, who reported that she and her husband had medical expenses totaling $41,000 in the past two years.
Senator Tom Udall, Democrat of New Mexico, told the story of a constituent, Kevin Kargacin, whose daughter Amber takes drugs costing more than $60,000 a year for multiple sclerosis. ''Kevin is scared because the cost of treating Amber's disease is so high,'' Mr. Udall said.
In an interview, Mr. Kargacin said he wrote to Mr. Udall because ''we are terrified that without the Affordable Care Act, Amber could be denied insurance or run into lifetime caps on expenditures for her treatment.''
Senator Amy Klobuchar, Democrat of Minnesota, said: ''Many Minnesotans have contacted me in the last few months, frightened about the future of their health care coverage. I heard from a man in Orono. His wife was diagnosed with cancer this year. On top of everything his family is now dealing with, he is terrified that his family will lose coverage if there is a repeal.''
Whether such concerns reflect a change in public opinion is difficult to say. Over the past six years, Republicans have collected stories from hundreds of constituents complaining that their insurance policies were canceled, their premiums have shot up and their deductibles are so high that the insurance is nearly worthless.
''Scott from Hickory has had his health insurance canceled three times now, disrupting his continuity of care,'' said Representative Virginia Foxx, Republican of North Carolina. ''Patricia from Kernersville now has a whopping $6,550 deductible.''
Representative Pat Tiberi, Republican of Ohio, reported that a constituent named Kimberly had difficulty obtaining treatment for a brain tumor because, she said, ''virtually no doctors take the marketplace insurance.''
The differing accounts are not necessarily in contradiction. Some people have benefited from the law while others have seen their coverage disrupted.
Republicans said the Obama administration had been slow to recognize and acknowledge problems with the Affordable Care Act. Administration officials said insurance rate increases of 25 percent or more were not a significant problem because low-income people could get subsidies to help defray the cost -- even though millions of people buying insurance on their own do not receive subsidies.
The administration insisted that insurance markets were ''stable and vibrant'' even as large insurers pulled out of Affordable Care Act exchanges where they were losing hundreds of millions of dollars. In 2015, the administration said that ''claims data show healthier consumers'' in the exchanges, but some insurers disputed that assessment, saying they had not seen an influx of healthy people to help cover the costs of sick people.
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GRAPHIC: PHOTOS: Rallies in protest of efforts to repeal the health law were held across the country over the weekend in places like Denver, left
Warren, Mich., center
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April 29, 2016 Friday
Late Edition - Final
Colorado Voters to Weigh Universal Health Coverage
BYLINE: By JACK HEALY
SECTION: Section A; Column 0; National Desk; Pg. 10
LENGTH: 1402 words
DENVER -- For years, voters in this swing state have rejected tax increases and efforts to expand government. But now they are flirting with a radical transformation: whether to abandon President Obama's health care policy and instead create a new, taxpayer-financed public health system that guarantees coverage for everyone.
The estimated $38-billion-a-year proposal, which will go before Colorado voters in November, will test whether people have an appetite for a new system that goes further than the Affordable Care Act. That question is also in play in the Democratic presidential primaries.
The state-level effort, which supporters here call the ColoradoCare plan, would do away with deductibles. It would allow patients to choose doctors and specialists without distinguishing between those ''in network'' and those ''out of network.'' It would largely be paid for with a tax increase on workers and businesses, and cover everyone in the state. Supporters say most people would end up saving money.
Insurance groups, chambers of commerce and conservatives have already lined up in opposition. They say the plan's details are vague, its size and cost galling. The proposed health system would have a budget bigger than that of Colorado's entire state government. A new 10 percent tax on payroll and incomes to pay for the system would push Colorado's tax rates to some of the highest in the nation.
The proposal's chance of success is dubious. Colorado has a mixed record when it comes to ballot measures, though it has passed some notable ones over the years, including marijuana legalization and the Taxpayer Bill of Rights, an anti-tax, anti-spending constitutional amendment.
But the proposal had enough support to garner 100,000 signatures, which put it on the ballot. It has also worried insurers, and some in the medical community and the business community, enough for them to organize in opposition, even enlisting a Democratic former governor to help in their campaign.
In this season of political discontent, the notion of dismantling the health insurance system has tapped an aquifer of frustration from voters. People say that even after the Affordable Care Act, they still pay too much in premiums, plus thousands in deductibles, and still have to worry about being bankrupted by a disabling car crash or an extended hospital stay.
''I think insurance is one of the biggest jokes and crooks,'' said Brandon Barta, 38, of Denver. He said his father, Dixon, who worked at a gas station, never received aggressive enough treatment for his prostate cancer. He died last May at the age of 64.
''He was overlooked,'' Mr. Barta said.
Mr. Barta said he was intrigued by the idea of a universal health plan that covered maternity care, checkups, emergency room visits and hospital stays, all the way through end-of-life care. Like millions of Americans, he has health insurance tied to his work. His coverage lapsed recently when he switched jobs to start working for a golf entertainment complex, and he is still waiting for his new plan to kick in.
Still, he has questions about how universal coverage would work and how much it would cost taxpayers like him.
The answers: If a majority of voters say yes, the system would start running in 2019, and essentially be a start-up health cooperative bigger than companies like Nike and American Express, according to the Colorado Health Institute, an independent policy group. A 21-person elected board would set the benefits and budgets. The system would be financed by payroll taxes of 3.3 percent for workers and 6.7 percent for employers. It would impose a 10 percent tax on investment income, people who are self-employed and some small-business income.
In the contest for the Democratic presidential nomination, Hillary Clinton, echoing many moderate Democratic leaders here, has said that she wants to keep and improve the Affordable Care Act, Mr. Obama's signature legislative legacy. But her opponent, Senator Bernie Sanders, who won Colorado's Democratic caucuses last month by nearly 20 points, has advocated abandoning the health law for a ''Medicare for all'' approach. His proposal is similar to the ColoradoCare plan.
The campaign over the Colorado initiative has had the unusual effect of putting conservative critics in the position of defending Mr. Obama's health plan against an assault from the left. At the same time, it is energizing progressives, who say the Affordable Care Act was a giveaway to the insurance industry that, even with an estimated 20 million people newly insured, has left too many others without coverage.
''No matter how long we hang in there with the Affordable Care Act, we will never cover everybody,'' said Jeanne Nicholson, a former Democratic state senator and nurse who is a leading supporter of universal care here. ''We don't understand why we should compromise and say some people can have bronze coverage, some can have silver and some can have gold. Why can't we all have platinum plus?''
Nathan Wilkes, 42, who lives in the Denver suburbs, said that years of trying to get care for his son, who has hemophilia, had worn his family thin and made him an advocate for universal coverage. He said the family had spent thousands of dollars and destroyed its credit because of insufficient coverage. The Affordable Care Act offered some benefits, he said, but its gaps were still too big and ''not sustainable.''
Unlike its conservative neighbors, Colorado jumped to get on board with the Affordable Care Act. It set up its own insurance marketplace and expanded Medicaid coverage for poorer residents. But there have been stumbles. People in mountain towns with few providers faced eye-popping premiums for coverage. Colorado's biggest health cooperative, Colorado HealthOP, shut down in October, forcing more than 80,000 people to find new plans.
Colorado's plan would replace many private workplace plans, but it would sit alongside Medicare and federal health coverage for veterans, and private insurers could still sell coverage to people who wanted more.
The Colorado Health Institute, an independent policy group, said the plan's passage would be ''the most far-reaching health care reform in any state'' since the Affordable Care Act.
''It's replacing a system that I think has become really dysfunctional,'' said Irene Aguilar, a Democratic state senator and physician who is leading the effort. ''The game has been rigged by the for-profit corporations to ensure they win.''
Opponents say that it could wreck the state's humming economy and drive away doctors and businesses, and that its costs could spiral out of control.
If it passes, ColoradoCare would become part of the state Constitution, and become virtually impossible to significantly alter without a statewide vote. It would also fall outside the reach of the Taxpayer Bill of Rights, a 1992 amendment to the Colorado Constitution that put strict limits on spending and new taxes.
''It would be a disastrous economic impact on the state,'' said Walker Stapleton, Colorado's treasurer and a co-chairman of the opposition campaign. ''If you think legalized pot brought a lot of people to Colorado, you should try free health care.''
Like many other Republicans here, Mr. Stapleton opposed the Affordable Care Act and continues to criticize how it has been put in place. But to defeat the new initiative, he now finds himself defending the federal health law.
Sean Duffy, a Republican and a spokesman for the opposition campaign, said many of his neighbors in the conservative Denver suburb of Highlands Ranch had eagerly signed the petition to put the question on the November ballot because they saw it as a way to get rid of Obamacare.
Some Democratic officials also oppose the state's universal care effort. They include Gov. John Hickenlooper, who said during his 2014 re-election fight that he was ''no big fan of the Affordable Care Act.''
Colorado's previous Democratic governor, Bill Ritter, also opposes it.
Michelle Lucero, general counsel at Children's Hospital Colorado, is among the health care officials lining up against the measure. (The hospital itself also opposes it.) She worries that it could threaten research dollars or drive away doctors.
''They're going to choose to go to a state that's not hamstrung by this,'' she said.
For the latest National news, follow @nytnational on Twitter.
URL: http://www.nytimes.com/2016/04/29/us/colorado-weighs-replacing-obamas-health-policy-with-universal-coverage.html
LOAD-DATE: April 29, 2016
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Nathan Wilkes of Englewood, Colo., says years of trying to get care for his son, Thomas, who has hemophilia, have made him an advocate of universal health coverage.
Michelle Lucero, general counsel at Children's Hospital Colorado, worries that universal health care in the state could threaten research dollars or drive away doctors. (PHOTOGRAPHS BY THEO STROOMER FOR THE NEW YORK TIMES)
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(First Draft)
January 11, 2016 Monday
Julian Castro Warns Latinos Would Suffer if G.O.P. Abandons Health Law
BYLINE: JOHN CORRALES
SECTION: US; politics
LENGTH: 320 words
HIGHLIGHT: Julián Castro, the federal housing secretary, said that if Republicans “recklessly” abandoned the Affordable Care Act without replacing it with “something thoughtful,” Latinos would “suffer tremendously.”
Julián Castro, the federal housing secretary, whom Hillary Clinton has mentioned as a potential running mate, said Monday that if Republicans "recklessly" abandoned the Affordable Care Act without replacing it with "something thoughtful," Latinos would "suffer tremendously."
Mr. Castro spoke at an event hosted by the Latino Network of The New York Times, where he discussed the role of Latino voters in the coming election.
Health care, Mr. Castro said, would be a major issue.
"Millions of Latinos have benefited from the Affordable Care Act," he said of President Obama's signature achievement, which most Republican candidates have pledged to reverse. "That has been the biggest beneficiary community from Affordable Health Care," Mr. Castro said, warning Republicans against repeal or efforts to "rearrange so much that it doesn't work."
Mr. Castro also talked about Senator Marco Rubio of Florida and Senator Ted Cruz of Texas, saying that each would have to reassure Latino voters that they would have their interests at heart. But, he added, political campaigns are about more than race.
"Rubio and Cruz, I believe that they're running the race they believe they have to run in order to win the Republican primary," Mr. Castro said, adding that President Obama's two successful White House campaigns depended on more than just African-American voters.
"So, in that sense, I don't begrudge Senator Rubio or Senator Cruz for not always reminding people that they're Hispanic," Mr. Castro said. "You need to represent the whole country."
As for his own potential role in a Clinton campaign, Mr. Castro said he had not yet been vetted or contacted by Mrs. Clinton about being her running mate, and he did not comment on whether he would entertain such an invitation.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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(Fiscal Crisis)
September 28, 2013 Saturday
Reid Calls House Bill 'Pointless' and Says Senate Will Reject It
BYLINE: Jeremy W. Peters
SECTION: US
LENGTH: 231 words
HIGHLIGHT: Before House Republicans could even vote on their plan to tie government funding to a one-year delay of the Affordable Care Act, the Democratic leader in the Senate declared the House bill dead-on-arrival and “pointless.”
Before House Republicans could even vote on their plan to tie government funding to a one-year delay of the Affordable Care Act, the Democratic leader in the Senate declared the House bill dead on arrival and "pointless."
"As I have said repeatedly, the Senate will reject any Republican attempt to force changes to the Affordable Care Act through a mandatory government funding bill or the debt ceiling," Mr. Reid said in a statement Saturday afternoon.
He continued: "To be absolutely clear, the Senate will reject both the one-year delay of the Affordable Care Act and the repeal of the medical device tax. After weeks of futile political games from Republicans, we are still at Square 1: Republicans must decide whether to pass the Senate's clean CR, or force a Republican government shutdown.
"Senate Democrats have shown that we are willing to debate and vote on a wide range of issues, including efforts to improve the Affordable Care Act. We continue to be willing to debate these issues in a calm and rational atmosphere. But the American people will not be extorted by Tea Party anarchists."
A Senate Democratic aide responded to the House's offer: "There is no change in plans on timing. We will wait and see, but it's highly unlikely we return before Monday. We are not playing games. House Republicans' only way out is to pass the Senate's clean [bill] or shut down the government."
LOAD-DATE: September 30, 2013
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(In Practice)
December 18, 2013 Wednesday
Broad Skepticism on Health Care Law
BYLINE: Megan Thee-Brenan
SECTION: US
LENGTH: 422 words
HIGHLIGHT: With the approach of the new year, when health insurance policies under President Obama’s new health care law are set to begin, there is wide skepticism among both the insured and uninsured about how the law will affect them and the nation as a whole, according to a New York Times/CBS News poll.
With the approach of the new year, when health insurance policies under President Obama's new health care law are set to begin, there is wide skepticism among both the insured and uninsured about how the law will affect them and the nation as a whole, according to a New York Times/CBS News poll.
The poll found that just one-third of uninsured Americans expect the law, the Affordable Care Act, to improve the nation's health care system, while the same proportion think the law will help them personally, according to the poll.
Overall, there is no consensus among uninsured Americans on how the health care system will fare once the law takes effect. While one-third expect improvement, two-thirds anticipate either a worsening or no difference at all.
"It will hurt everybody in the long run," said Cat Ping, 55, of Indianapolis in a follow-up interview. Ms. Ping, who does not have insurance, added: "I don't care how they spin it, Obamacare is not affordable. It's wrecking our total economy."
On the whole, uninsured Americans expect to be personally affected by the Affordable Care Act more so than all adults nationwide. Among all adults, nearly half think the law will not affect them at all, while among uninsured adults, just over one-quarter say that. And while a nearly 4 in 10 plurality of uninsured Americans think the health care law will hurt them personally, they are twice as likely as the general public to say the law will help them.
"I'm for universal health care, and this is a steppingstone in the right direction, " said Don Sears, 58, of Syracuse, N.Y. Mr. Sears, who has had health insurance on and off throughout the years, is currently unemployed and does not have insurance. He is looking forward to that changing, he said, because "with Obamacare I will be able to get health care" that is affordable.
The New York Times/CBS News poll was conducted among 1,000 adults nationwide by telephone on Dec. 5-8, 2013, and among 702 uninsured adults between Dec. 4-15. The margin of sampling error is plus or minus three percentage points among the general population and plus or minus five percentage points among the uninsured sample. Complete results of the survey will be available tonight at 6:30 p.m. on nytimes.com.
Awareness Grows of Online Insurance Exchanges, and Their Problems, Survey Finds
Closer Look at Polls Finds Views of Health Law a Bit Less Negative
Parties in California Squabble Over Another Website
Enrollment Numbers Rise After Website Improves
Programmers Find New Way to Navigate Health Plans
LOAD-DATE: December 18, 2013
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The New York Times Blogs
(Taking Note)
October 18, 2013 Friday
Is the Health Care Fight Over?
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 388 words
HIGHLIGHT: Despite the failure of the shutdown, some on the right-wing will keep trying to dismantle the Affordable Care Act.
Leading up to the crisis in Washington, the right-wing of the right-wing party stressed that blocking the continuing resolution was essential because it represented the last, best chance to stop the Affordable Care Act. "Last, best chance" was actually a mantra of sorts. "This is our last chance and our last best chance to do something about this," said Senator Marco Rubio, Republican of Florida, on the Senate floor in late July. "[T]his may be the last best chance to defund Obamacare before it goes into effect," the political group FreedomWorks argued over the summer.
Now that the shutdown has come and gone, some Republicans recognize that the defund-or-shutdown tactic was doomed to fail. "I think we have fully now acquainted our new members with what a losing strategy that is," Senate Republican Leader Mitch McConnell said on Thursday.
But many are vowing to keep fighting health care reform.
On Wednesday, Mr. Rubio predicted that there would "be an all-out revolt in this country" over the Affordable Care Act. And when that happens "that is, I think, the moment to absolutely act and say we are going to get rid of this law and then look for opportunities in the future to replace it."
The next day, Senator Ted Cruz said "I would do anything, and I will continue to do anything, to stop the train wreck that is Obamacare."
Matt Kibbe, the president of FreedomWorks, told The Washington Post that he plans to hold rallies with young people who oppose the individual mandate.
And in an op-ed Thursday for The Wall Street Journal, Jim DeMint, president of the Heritage Foundation, claimed there was no good reason for him to back down. Sure, the president won re-election, but "ObamaCare was not the central fight in 2012." Sure, full repeal is probably impossible while a Democrat's in office, "but delaying implementation by withholding funds" is "a reasonable and necessary fight." By keeping the national focus on health care, moreover, Republicans can avoid negotiating other issues. "If the Republicans had not fought on Obamacare, the compromise would have been over the budget sequester."
Last and best, it turns out, can mean one of many.
House Republicans Should 'Knock it Off'
Is Health Care Reform Creating More Part-Time Work?
John McCain Versus Ted Cruz
Ted Cruz Plays Two Truths and a Lie
G.O.P. Purity Control
LOAD-DATE: October 18, 2013
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The New York Times
March 16, 2017 Thursday
Late Edition - Final
Don't Try to Fix Obamacare. Abolish It.
BYLINE: By ERICK-WOODS ERICKSON.
Erick-Woods Erickson is the editor of the website The Resurgent and a talk-show host on the radio station WSB.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 23
LENGTH: 907 words
ATLANTA -- As Republicans in Washington grapple with altering the Affordable Care Act, they have proceeded in a direction that will do little to curb the cost of health care in America.
Instead, they are pushing a bill that, according to the Congressional Budget Office, might save the government money, but will end coverage for 24 million people (though several million of those would be willingly giving up coverage the law now requires them to have). If it passes, Republicans will not only own the nation's health care problems for years, but they will also have violated more than six years of promises.
Since 2010, Republicans have pledged to repeal -- not fix, not tinker with, but abolish -- Obamacare. In 2016, that was a centerpiece of Donald Trump's campaign. Republicans ran advertisements noting they had voted 70 or more times to repeal the Affordable Care Act, and they would do it as soon as they had control of Congress and the White House.
Voters gave them just that. And now Republicans, who had used the word ''repeal'' like a meditation chant, act like the proverbial dog that caught the car. The plan they all liked in 2015 -- one that would have ended the law's mandates, subsidies and Medicaid expansion -- would not pass today. Yes, Republicans, you really did once author a plan to credibly repeal Obamacare, unlike what you are considering now.
Of course, Republicans are acting this way in large part because of President Trump's voters. Despite all the hard talk about repealing Obamacare, Mr. Trump's voters supported a man who promised a government-run health care plan that would provide universal coverage. In other words, he promised more than Obamacare. For that matter, Mr. Trump promised more government involvement in health care than Hillary Clinton did. It is not hard to see why Republicans think they can get away with breaking their promises. Their own party's presidential nominee promised more than what President Obama offered and claimed he could pay for it all without raising taxes.
Mr. Trump's voters want Obamacare, but they want Mr. Trump's gold-plated branding on it. They claim to hate Obamacare, but data show a good number of Mr. Trump's voters are actually using the Affordable Care Act. Just don't tell them that the Affordable Care Act is Obamacare. They like the former and hate the latter.
The 2016 election was, though it pains me to say, a defeat for conservatism. Both parties were willing to gravitate toward candidates who promised a strong federal government that could deliver a panacea without worrying about costs. Mr. Trump promised to be a strong man stamping out waste, fraud and abuse while putting Americans first. His voters are smart enough to understand that his programs will cost money. They just do not seem any more concerned than Republican leaders in Washington about budget costs. They all make a great show of caring in public, but it is just show.
So Democrats and Republicans are fighting over who gets to expand government for which voters and by how much. The Republicans, who claim to be the party of fiscal discipline, want to spend money, but at a slower pace than the Democrats and without raising taxes. It did not have to be this way. The Republicans did not have to embrace the Democrats' presuppositions in creating Obamacare.
Despite the name ''Affordable Care Act,'' the Democrats were far more focused on expanding coverage and ensuring every American could get insurance than they were on making coverage affordable. When Republicans decided to amend Obamacare, they too focused on the numbers covered.
Instead, they should focus on cost.
If Republicans stopped worrying about how many people had access to a government-managed health care program and started focusing on reducing costs, they could potentially increase the number of people covered. Doing so would necessitate scaling back the government's involvement in health care, reducing insurance mandates, unleashing free-market competition among insurance providers and allowing consumer choice in selecting plans.
Increasing competition and choice would lower prices for all kinds of insurance. Lower prices would free up corporate dollars for other things like innovation and jobs. Lower prices would also make it far more affordable for Americans to buy their own insurance than wait for government to subsidize it.
For conservatives like me, however, it appears the train has left the station. Democrats and many Republicans are invested in the idea of involving government in our basic health care choices. The Republicans are even keeping President Obama's individual mandate, though in repackaged form.
Americans are increasingly cynical about politics. Watching Republicans campaign for years on repealing Obamacare only to see the effort collapse will just increase that cynicism. But the reverse is true, too. Watching many Americans demand repeal, while voting for a man who promised a government-run, universal coverage solution, only increases politicians' cynicism about the American voter. The voters know the politicians will break their promises once elected. The politicians know the voters will let them get away with it as long as the spoils of victory are divvied up.
Paying the bill will be a problem for some other day.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTOpinion), and sign up for the Opinion Today newsletter.
URL: http://www.nytimes.com/2017/03/15/opinion/erick-erickson-dont-try-to-fix-obamacare-abolish-it.html
LOAD-DATE: March 16, 2017
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The New York Times
January 6, 2017 Friday
Late Edition - Final
The Health Care Law, Imperiled
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 18
LENGTH: 578 words
To the Editor:
Re ''Senate G.O.P. Opens Fight Over Obama Health Law'' (front page, Jan. 5):
Given that the Republicans in Congress have offered nothing more than the lies of their own manufactured outrage to justify the haste and glee with which they are about to dismantle Obamacare, their actions can only be seen as a final act of political retribution against a president they never accepted or planned to work with in good faith.
The fact that more than 22 million people may lose access to health coverage as a result of this act of political callousness only cements the perception that the Republican Party is a morally and ethically bankrupt party that cannot be trusted to govern or participate responsibly in our democracy.
MICHAEL SCOTT
San Francisco
To the Editor:
Re ''Republicans' Four-Step Plan for Dismantling the Care Act'' (front page, Jan. 5):
As a physician, I have seen firsthand the transformation of our health care system under the Affordable Care Act. The law is imperfect, as all laws are, but it has provided the necessary framework to control costs (and would be working even better if the incremental changes it needs had not been blocked by a hostile Congress for six years).
In its most important mission -- bringing health insurance to all Americans, including those previously uninsurable because of pre-existing conditions -- the law is a resounding success. I can state without equivocation that I have cared for patients who owe their lives to the Affordable Care Act, and that full repeal of this law will kill people.
NIKHIL SINGH
New Haven
The writer is a nephrology fellow at the Yale School of Medicine.
To the Editor:
President Obama's Affordable Care Act is not the culprit in the disaster that is the distribution of health care in America.
The most powerful Congressional lobby today is not the National Rifle Association or the military-industrial complex. It is the vast health-care-industrial complex, stretching across insurance, pharmaceutical and medical supply companies and down to hospitals and the American Medical Association, each feeling entitled to a share of the patient's wallet.
This is the capitalist ethic at its worst.
Republicans and libertarians cavalierly rail against entitlements and ''people living off the public's dime'' but remain silent on those profiting from people's misfortune and illness.
It will be interesting to see how Donald Trump's billionaire cabinet, secure and insured in its entitled wealth, will approach reforming Obamacare.
ROBERT PORATH
Boulder, Colo.
To the Editor:
Re ''Safety-Net Hospitals Fear Cuts as Health Law's Repeal Looms'' (front page, Dec. 28):
Simply put, hospitals that disproportionately serve Medicare and Medicaid patients (and thus very few commercially insured patients) are financially unsustainable because of severe underpayments.
In New York State alone, 27 hospitals are on a ''watch list'' for financial vulnerability, and many more are in similar fiscal distress. Repealing the Affordable Care Act without an immediate and adequate replacement will make things dramatically worse.
The health law is far from perfect, and long-term improvements are certainly necessary. But Washington would be wise to avoid decisions that will severely -- and perhaps irreparably -- harm America's safety-net hospitals and the vulnerable communities they serve.
KENNETH E. RASKE
President, Greater New York
Hospital Association
New York
URL: http://www.nytimes.com/2017/01/05/opinion/the-health-care-law-imperiled.html
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The New York Times
March 17, 2017 Friday
Late Edition - Final
Trump and G.O.P. Work to Win Repeal of Obama's Health Care Act
BYLINE: By ROBERT PEAR and JONATHAN MARTIN; Jonathan Martin contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1295 words
WASHINGTON -- President Trump and House Republican leaders worked Thursday to win conservative support for legislation to repeal the Affordable Care Act, offering concessions to speed cutbacks in Medicaid and dismantle more of President Barack Obama's signature health law.
But in a bid to ensure passage of the Republican health care bill in the House, White House and Republican leaders risked losing support in more moderate quarters of their party -- not only in the narrowly divided Senate, but in an increasingly nervous House.
A faster path to Medicaid cuts, new work requirements for Medicaid recipients and potentially smaller tax credits for the working poor could mollify conservatives who are pressing for a smaller government footprint on the health care system, but they would cut deeper into the benefits that many Trump voters have enjoyed under the Affordable Care Act.
White House officials have made clear that they are open to supporting amendments that would require a quicker end to the expansion of Medicaid under the 2010 health care law, according to an administration official involved in negotiations with Congress.
Representative Joe L. Barton, Republican of Texas, and other conservatives want to freeze the expansion of Medicaid next year, two years earlier than under the legislation drafted by House Republican leaders. Referring to this change, Mr. Barton said, ''The Trump administration is open to it.''
But in an interview, Representative Leonard Lance, Republican of New Jersey, said: ''I am opposed to that. New Jersey expanded Medicaid. I don't want that to be eliminated.'' The federal government pays at least 90 percent of Medicaid costs for newly eligible beneficiaries, and Mr. Lance said, ''I would like that to continue for at least several years.''
Speaker Paul D. Ryan said Mr. Trump was now fully engaged.
''This president is getting deeply involved,'' Mr. Ryan said. ''He is helping bridge gaps in our conference. He is a constructive force to help us get to a resolution.''
The political stakes for the president and the speaker could hardly be higher. If they succeed in undoing the Affordable Care Act, it would add momentum to efforts to enact other items on their agenda, such as tax cuts and a rewrite of the tax code. If they fail, it would embolden Democrats keen to block Mr. Trump -- and conservatives still seeking to imprint their hard-line policies.
But they are in a delicate dance with conservatives and moderates. Halting the expansion of Medicaid in 2018, rather than in 2020, ''would be a huge problem, enormously problematic,'' said Representative Charlie Dent, Republican of Pennsylvania, one of 31 states that have expanded eligibility for Medicaid under the Affordable Care Act.
House Republicans appeared determined to power through, despite divisions in their ranks. On Thursday, the House Budget Committee approved a motion to send the repeal bill to the full House, where Republican leaders plan to take it up this month.
But the 19-to-17 vote in the Budget Committee portends possible difficulties. Three conservative Republicans -- Dave Brat of Virginia, Gary Palmer of Alabama and Mark Sanford of South Carolina -- voted no, joining a united Democratic opposition.
''This legislation is a conservative vision for free-market, patient-centered health care,'' said Representative Diane Black of Tennessee, the chairwoman of the Budget Committee. ''It dismantles Obamacare's mandates and taxes. It puts health care decisions back in the hands of patients and doctors.''
The Budget Committee endorsed a Republican proposal suggesting that the bill could be improved by imposing work requirements on certain Medicaid beneficiaries -- able-bodied adults without minor children. Representative Glenn Grothman, Republican of Wisconsin, said that Medicaid in its current form was ''a seductive entitlement'' that encourages people ''not to work at all, or to work less.''
That change would have to be made later in the legislative process; the committee approved a motion directing Ms. Black to seek an amendment authorizing work requirements.
Republican leaders acknowledged that they did not yet have the votes to ensure that the full House would pass the repeal bill, but Mr. Ryan said he was ''working hand in glove'' with Mr. Trump to achieve that goal.
Mr. Trump ''knows how to connect directly with people,'' Mr. Ryan said
House passage, Mr. Trump's aides believe, would force the Senate Republican holdouts to consider whether they would be willing to vote against repeal of a law they have been pledging to undo for seven years.
To make opposition even harder for Senate Republicans, Mr. Trump's aides plan to deploy him to states he won where Republican senators may be uneasy about the current legislation.
With no hope of winning support from Democrats, Ms. Black appealed to members of her party.
''To my Republican colleagues who have doubts,'' Ms. Black said, ''I encourage you: Don't cut off discussion. Stay in this effort and help us enhance this proposal by advancing it out of committee and pushing for further conservative reforms. Members who desire to see this bill improved have every right to make their voices heard.''
Last week, Mr. Ryan appeared to reject major changes sought by conservatives, saying, ''It really comes down to a binary choice'' between the repeal bill and that status quo.
But on Wednesday, after a meeting of the House Republican Conference where Vice President Mike Pence tried to rally support for the legislation, Mr. Ryan opened the door to changes, saying, ''We can make some necessary improvements and refinements to the bill.''
The bill would eliminate tax penalties for people who go without insurance and create a new system of tax credits to help people buy private insurance. It would roll back the expansion of Medicaid authorized by the Affordable Care Act and give each state a fixed allotment of federal money to provide health care to low-income people on Medicaid.
Beyond the faster end to the Medicaid expansion and work requirements for some Medicaid beneficiaries, some conservatives are still pressing to limit the size of the tax credit for the purchase of insurance to no more than the amount of federal income taxes a recipient owes. That would further hurt low-income consumers who may owe little or nothing in income taxes, and under the current proposal would receive financial assistance from the government to help offset insurance costs.
Democrats on the Budget Committee found support for their case in a report issued this week by the nonpartisan Congressional Budget Office. The report estimated that the House Republican bill would increase the number of people without insurance by 14 million next year and by 21 million in 2020. ''In just three years,'' said Representative John Yarmuth of Kentucky, the ranking Democrat on the Budget Committee, ''the entire gains under the Affordable Care Act will be wiped out.''
Some 20 million uninsured people have gained coverage under the law, which was signed by Mr. Obama seven years ago.
Representative Sheila Jackson Lee, Democrat of Texas, said: ''This is a bust-Medicaid bill. It is not a health care bill.''
Representative John J. Faso, Republican of New York, had previously raised questions about a provision of the bill that would cut off federal funds for Planned Parenthood clinics.
But on Thursday he said the overall bill was needed to protect people against potential harm from the health law. ''Many people across the country are happy with the Affordable Care Act,'' Mr. Faso said. ''But just as many, if not more, are seeing extraordinary increases in premiums, extraordinary increases in deductibles. They can no longer afford it.''
URL: http://www.nytimes.com/2017/03/16/us/politics/health-care-repeal-affordable-care-act.html
LOAD-DATE: March 17, 2017
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Representative Jason Lewis, Republican of Minnesota, during a hearing on Thursday on the bill to repeal the Affordable Care Act.
Members of the House Budget Committee, which approved a motion to send the bill to repeal the health act to the full House. (PHOTOGRAPHS BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES)
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The New York Times
March 24, 2017 Friday
The New York Times on the Web
Lacking the Votes for Passage, House Calls Off Obamacare Repeal Vote
BYLINE: By THOMAS KAPLAN, ROBERT PEAR and EMMARIE HUETTEMAN
SECTION: Section ; Column 0; Washington; LIVE BRIEFING; Pg.
LENGTH: 1089 words
â- President Trump plans to meet Thursday at 5 p.m. with moderate House Republicans in the Tuesday Group, a group of moderate Republicans.
â- House Republicans will meet at 7 p.m. to discuss a path forward.
â- The vote scheduled Thursday on the House plan to repeal the Affordable Care Act was postponed, possibly until Friday.
No deal on a health bill -- yet.
Members of the hard-line House Freedom Caucus emerged from a negotiating session with President Trump without an agreement on changes to Republican's health care bill that would satisfy them. But they were closer.
''We're certainly trying to get to 'yes,''' said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. ''We've made very reasonable requests and we're hopeful that those reasonable requests will be listened to and ultimately agreed to.''
Sean Spicer, the White House press secretary, said the president had agreed to the conservatives' demands that the bill strip out a set of ''essential benefits'' required of insurance policies by the Affordable Care Act. Those include emergency services, ambulance coverage, maternity care and preventive health care.
He also confirmed that the latest version of the bill would repeal all tax increases in the Affordable Care Act this year and would add additional restrictions on Medicaid payments.
Trump works to persuade reluctant Republicans.
Ahead of his meeting with the House's most hard-line conservatives, President Trump released a video pitch for the House plan to repeal and partially replace the Affordable Care Act. Bottom line: ''Go with our plan. It's going to be terrific.''
You were given many lies with #Obamacare! Go with our plan! Call your Rep & let them know you're behind #AHCA â[#x17e]¡ï¸ https://t.co/xAX4GJiO8z pic.twitter.com/qp90G49e0j -- President Trump (@POTUS) March 23, 2017
But as Mr. Trump and House leaders focus on the Republican Party's conservatives, they are losing House moderates.
The most recent defections came from Representatives Jaime Herrera Beutler of Washington and Mark Amodei of Nevada. Ms. Herrera Beutler's statement said, ''But we can do better than the current House replacement plan, and I cannot support it in its current form.''
My statement on the scheduled vote on the House health care bill:https://t.co/JU2NQPnAoW -- JaimeHerreraBeutler (@HerreraBeutler) March 23, 2017
Mr. Amodei was no less certain.
We've done our homework. We've closed on the issue in preparation for a vote tonight. I'm a no on the #AHCA -- RepMarkAmodei (@MarkAmodeiNV2) March 23, 2017
Obama speaks out on repealing his health law.
Former President Barack Obama has been remarkably quiet as Republicans in Congress and Mr. Trump work to dismantle his signature domestic achievement.
On the seventh anniversary of the Affordable Care Act's signing, Mr. Obama released a statement.
His bottom line: The health care law is working, but it could be improved if Republicans and Democrats work together.
''The reality is clear: America is stronger because of the Affordable Care Act. There will always be work to do to reduce costs, stabilize markets, improve quality, and help the millions of Americans who remain uninsured in states that have so far refused to expand Medicaid. I've always said we should build on this law, just as Americans of both parties worked to improve Social Security, Medicare, and Medicaid over the years. So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they're prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals -- that's something we all should welcome. But we should start from the baseline that any changes will make our health care system better, not worse for hardworking Americans. That should always be our priority.''
One poll finds public support lacking for health bill.
A new poll by Quinnipiac University put support for the Republicans' American Health Care Act at 17 percent, with 56 percent opposed and 26 percent undecided. Even support among self-described Republicans is not terribly high, 41 percent in favor and 24 percent opposed.
Only 13 percent of women said they favored the health proposal.
Pelosi denounces 'a moral monstrosity.'
As Republicans intensified their arm-twisting, Representative Nancy Pelosi of California, the Democratic leader, panned the health care measure as ''a moral monstrosity'' on Thursday.
She also engaged in a little taunting, criticizing President Trump and Republicans for their 11th-hour efforts to bring party members on board.
''May be a great negotiator, Donald Trump,'' she said with a smile. ''Rookie's error bringing it up in a day.''
Senate Democrats are not in a cooperative mood.
Even if the Republicans' American Health Care Act can find its way through the House, the eye of the Senate needle is even narrower.
Forty-three Senate Democrats put Mr. Ryan on notice in a letter that they had no intention of cooperating with Republicans to complete a remake of the American health care system. Mr. Ryan said the Republican remake will come in three ''prongs.'' The first will be passage of legislation through the budget process that guts the Affordable Care Act, protected by arcane parliamentary rules from a Democratic filibuster.
The next ''prong'' would be regulations issued by the Department of Health and Human Services. And the final ''prong'' would be substantive changes to the health care system that would require 60 votes in the Senate -- and Democratic cooperation.
That isn't happening, Senate Democrats declared in the letter.
''We are writing today to inform you that our caucus will not support any efforts that jeopardize the consumer protections our constituents rely upon when they purchase insurance.''
Specifically, they said they would not tolerate the conservative push to eliminate so-called ''Essential Health Benefits'' mandated for insurance policies issued under the Affordable Care Act, which include maternity care, emergency services, ambulance services and preventive health care.
''We will oppose any efforts to lessen our constituents' access to basic preventative and primary care,'' the senators said. ''Undermining the value of insurance and requiring that insurance plans cover rudimentary health care services is simply shifting more costs onto patients and taxpayers.''
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URL: http://www.nytimes.com/2017/03/23/us/politics/health-care-trump-vote.html
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September 3, 2013 Tuesday
Business Owners Say They Have Yet to Figure Out Health Care
BYLINE: ADRIANA GARDELLA
SECTION: BUSINESS; smallbusiness
LENGTH: 804 words
HIGHLIGHT: One owner says she is having trouble pitching clients and budgeting because she does not know what her costs will be.
At the last meeting of the She Owns It business group, we talked about how, if at all, the owners expect the Affordable Care Act to affect their businesses. Several group members - Alexandra Mayzler, Jessica Johnson, and Susan Parker - were unable to attend the meeting, but they offered their thoughts in individual conversations afterward. (We had also discussed health care in a previous post.)
"I am woefully undereducated about Obamacare," conceded Deirdre Lord, who owns the Megawatt Hour.
Beth Shaw, the owner of YogaFit, said she felt the same way.
Susan Parker said she doesn't know how the Affordable Care Act would affect her business, Bari Jay. "I would be shocked if anyone really knows," she added. She does, however, think premiums will go up and that small-business owners will wind up paying more. Bari Jay pays more than 50 percent of the cost of health insurance for its 16 employees. She doesn't think any of them are uninsured, though most don't use the company plan, which she acknowledges isn't the best.
For Ms. Parker, the anticipated Oct. 1 start of open enrollment for the New York State Health Benefit Exchange raises nothing but questions. For example, how will Bari Jay's costs be affected if employees choose to get insurance through the exchange instead of the company? Will Bari Jay have to continue paying to cover employees who make that choice? Will it have to contribute for employees who take advantage of a spouse's plan?
Ms. Lord is also wondering how, or whether, her company will be affected when enrollment opens for the exchange. The Megawatt Hour does not subsidize health insurance for its five employees, but it does offer a plan at what she says she believes are better rates than an individual would get. So far, there have been no takers. The employees are either on their spouse's plan or their parents', she said. The company will re-evaluate its plan this fall, as it does every year.
"I would imagine getting the insurance broker out of the way is a huge savings because I think these people are taking a nice piece of the action," said Ms. Shaw, whose company offers health insurance for its 12 employees and covers 50 percent of the cost. She added that fewer than a quarter of her employees are on the plan. She suspects that's because the staff is young. "I think they just don't think about it," she said.
Alexandra Mayzler, who owns Thinking Caps Group, said, "I haven't even had time to think about Obamacare - we've been offering insurance, so I'm not worried." Specifically, Thinking Caps covers a portion of the cost of health insurance for its full-time employees - and a smaller portion for those who choose to buy their own insurance. "What I am worried about is extra paperwork," she added.
Jessica Johnson, the owner of Johnson Security Bureau, said she understood how the Affordable Care Act was supposed to play out - hypothetically, at least. Still, she has questions about the specifics. With 115 employees, her company is not considered a "small business" pursuant to the new law, which means, among other things, that it won't be able to buy insurance through the small-business exchange.
Ms. Johnson said she was glad the effective date of the employer mandatehad been postponed a year, to January 2015. According to the mandate, employers with more than 50 employees must offer their employees health insurance plans with monthly premiums that do not exceed 9.5 percent of an employee's gross wages. Those who don't will be fined. Providing this insurance, in 2014, likely would have cost her company close to $220,000, Ms. Johnson said. Before the mandate was postponed, she had started searching for more affordable plans, and meeting with her company's clients to discuss potential price increases. Not surprisingly, she encountered some reluctance.
Johnson Security offers a health insurance plan or health care savings accounts to all of its employees. The plan's monthly premium is more than $500, and employees have to chip in. From 2012 to 2013, premiums increased 16 percent, she said.
Looking ahead to 2015, Ms. Johnson said she was facing a challenge. Prices are not yet available for 2015 insurance plans. "We can't even do a budget," she said. As a result, she said, she has had to walk away from prospective clients who can't work these contingencies into their contracts.
"I just want Obamacare to make sense for my situation," she said. Otherwise, she asked, "What incentive do I have to put more people to work?"
You can follow Adriana Gardella on Twitter.
Employer Mandate, Delayed by Paperwork (and Efforts to Reduce It)
It's the Affordable Care Act. But What Is Affordable?
In the Affordable Care Act, Some Children Left Behind
A Bakery Is Relieved to Have the Employer Mandate Delayed
Could Employers Use Immigrants to Avoid the Health Mandate?
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March 5, 2015 Thursday
Today in Politics
BYLINE: THE NEW YORK TIMES
SECTION: US; politics
LENGTH: 1852 words
HIGHLIGHT: Senate Democrats are increasingly alarmed about the fate of Ms. Lynch, with no announced plans for floor consideration of her nomination as attorney general and just the bare minimum number of Republicans necessary for confirmation expressing support for her.
Democrats Fret as Lynch Nomination Languishes
Good Thursday morning from Washington, where Hillary Rodham Clinton set the Internet aflutter with a late-night tweet saying that she wanted the public to see her emails and that she had asked the State Department to release them. The Supreme Court is again considering the future of the Affordable Care Act, and we look at whether this is the last hope for Republican dreams of dismantling the law. But first up, after months of limbo, Democrats are more than ready to get a move on with Loretta E. Lynch's confirmation as attorney general.
Senate Democrats are increasingly alarmed about the fate of Ms. Lynch, with no announced plans for floor consideration of her nomination as attorney general and just the bare minimum number of Republicans necessary for confirmation expressing support for her.
Republicans say opposition to Ms. Lynch has grown since a January confirmation hearing where she defended President Obama's actions on immigration, indicating that Republicans see a vote against her as a way to vent frustration over the president's moves.
Senator Susan Collins of Maine intends to back Ms. Lynch, joining three other Republicans on the Judiciary Committee who supported her. If all 46 Democrats back her, that gives Ms. Lynch 50 votes, with Vice President Joseph R. Biden Jr. as a potential tiebreaker in her favor. Supporters of Ms. Lynch want a stronger showing and are holding out hope for backing from Republicans such as Senator Lisa Murkowski of Alaska, who said she remained undecided.
Senator Mitch McConnell of Kentucky, the majority leader, has given no indication of when he intends to bring the nomination to the floor, though his aides say she is assured of a vote at some point.
Hoping to spur action, Democrats are stepping up their push for a resolution on Ms. Lynch, who would be the nation's first African-American, female attorney general. Senators Patrick J. Leahy of Vermont and Charles E. Schumer of New York are circulating a letter to Mr. McConnell saying that Democrats are "troubled that her nomination continues to languish."
"There is simply no credible reason for further delay," it says.
- Carl Hulse
Stay tuned throughout the day @NYTpolitics for First Draft updates
Is Health Law Hearing a Last Hope for Republicans?
For all the damage that a loss in the Supreme Court would do to President Obama's health care law, a White House win might cause even more pain for his Republican adversaries.
For years, conservatives have raged against the Affordable Care Act, seeking any way possible to repeal what is likely to be Mr. Obama's signature domestic accomplishment. They have voted more than 50 times to legislate it out of existence. And they have sought help from the judicial branch, only to be rejected by the Supreme Court in their first challenge, in 2012.
Now, the fate of the law once again rests with the nine justices, who heard arguments from both sides on Wednesday. The court appeared to be split on the issue, but the observers said the justices were tough in grilling the lawyers who are challenging the law.
If conservatives lose for a second time in the highest court, it would be a blow to the movement against the Affordable Care Act. It would signal that the court is in no mood to get rid of the health law and would force the conservative legal movement back to the drawing board.
Republican lawmakers are still fashioning plans to overhaul the Affordable Care Act, perhaps with the hope that 2016 brings a Republican president who would actually sign such legislation. And Speaker John A. Boehner of Ohio is still pursuing a lawsuit claiming that Mr. Obama exceeded his authority by unilaterally changing the timeline for its execution.
Michael S. Greve, a law professor at George Mason University, said he and his colleagues wouldn't give up if they came up short again at the Supreme Court. "In any law that size, there are bound to be things nobody has seen," he said. "Those shoes, too, might well drop."
But execution of the law, which already provides health insurance for 11.5 million people, would march on. For Mr. Obama, the rewards of the court case could be as large as the risks.
- Michael D. Shear
Awaiting Ruling, G.O.P. Seeks Health Act Alternatives
The legal campaign to destroy the Affordable Care Act may be nearing the end of the road, but the Republican legislative search for a viable replacement appears to be finally gaining steam.
Senior Republicans in Congress - hoping for a Supreme Court decision in King v. Burwell that would force the issue - have begun uniting around serious ideas that are likely to live beyond the Supreme Court's final judgment. Those plans would not cover as many uninsured as the Affordable Care Act, but that is not necessarily the point. Where Democrats have long emphasized expanding coverage, Republicans have stressed lowering cost.
On Monday, Representatives Paul D. Ryan of Wisconsin, Fred Upton of Michigan and John Kline of Minnesota, the chairmen of the committees that control health policy, proposed in The Wall Street Journal what they called an "off ramp" from the Affordable Care Act. States would be able to opt out of its individual and employer coverage mandates, and insurance policies would no longer have to meet the minimum standards the law sets.
But the House plan would maintain generous tax credits for the purchase of private insurance policies, including "refundable" tax credits for those who earn too little to owe income taxes. The three would keep the Affordable Care Act's most popular elements: allowing children to stay on their parents' policies until age 26, prohibiting lifetime coverage limits and protecting people with existing health problems.
In the Senate, Republicans are rallying around an even broader health proposal written by Senators Orrin G. Hatch of Utah and Richard M. Burr of North Carolina. Even a freshman, Senator Ben Sasse of Nebraska, took to The Journal's editorial page to propose a major expansion of Cobra to ensure that people do not lose insurance coverage if the Supreme Court decides against the administration.
"Republicans need to unify around a specific set of constructive, longer-term solutions, and then turn the 2016 presidential election into a referendum on two competing visions of health care," he wrote. "Simply opposing Obamacare isn't enough. Republicans must address this country's health care crises: cost and uninsurance."
Through the magic of congressional budget rules, known as reconciliation, large parts of the emerging Republican plans could be passed by Congress with a simple majority. President Obama would still be able to veto the legislation, but if Republicans are ready to legislate, their majorities in both houses could give them the tools.
- Jonathan Weisman
Bulletins: Clinton Emails, Rubio Skips Iowa, Van Hollen Runs
Hillary Rodham Clinton said on Twitter that she had asked the State Department to release tens of thousands of work-related emails that she sent from her personal email account when she was secretary of state. She asked the department to prepare the release so it could determine whether parts should be redacted because they contain information that could be damaging to national security.While attention around Mrs. Clinton has been focused on her email use, her team quietly brought on a new lawyer for her campaign-in-waiting two months ago.
Senator Marco Rubio of Florida withdrew from an agriculture forum in Iowa planned for Saturday, one of the largest gatherings of Republican 2016 presidential hopefuls so far, reducing the R.S.V.P.s from 11. Mr. Rubio, who has increasingly signaled that he will enter the race, cited a family wedding that conflicted with the Iowa Ag Summit.
The race to replace retiring Senator Barbara A. Mikulski of Maryland is officially on. Representative Chris Van Hollen, also a Democrat, said on Wednesday that he was listening to those who had urged him to run and that he looked forward to "a healthy exchange of ideas" in his campaign.
Sledding Gets Political Ahead of Washington Snow
Congress wasn't about to wait around to see how much snow accumulated in Washington on Thursday. The House and Senate called it a week on Wednesday, setting off the usual commentary about the capital's inability to weather significant weather.
"This place can't manage precipitation of any type," said Representative Charlie Dent, Republican of Pennsylvania. "Where I live, we deal with it. But not here."
With Congress gone, why not allow people to take advantage of the hill in Capitol Hill on what could be a serious sledding day? Eleanor Holmes Norton, the congressional delegate from the District of Columbia and a resident of the neighborhood, wrote to the Capitol Police, urging them to overturn a ban on sledding on the Capitol grounds.
"This could be the last snowstorm the D.C. area gets this winter, and may be one of the best for sledding in years," she said, calling for a one-time waiver and a later review of the ban. Senator Harry Reid, the Senate Democratic leader, tweeted his support.
Alas for sledders, Ms. Norton's request got the cold shoulder from Capitol authorities.
- First Draft
What We're Watching Today
President Obama will be snowed in at the White House. A daily briefing and lunch with Vice President Joseph R. Biden Jr. are the only events on his schedule.
Senator Tim Kaine of Virginia is expected to hold a conference call with national religious leaders about the impact of a Supreme Court ruling against the Affordable Care Act.
Local lawmakers in Washington are holding an event on the D.C. statehood movement.
Economic data on jobless claims, factory orders and labor market productivity are set to be released.
Our Favorites From Today's Times
Setting up secure, private email domains was no small task for the Clintons.
As the Justices heard arguments over the Affordable Care Act, the tea leaves were difficult to read.
Democrats are helping President Obama by giving him some needed breathing room while negotiating with Iran.
Jeremy W. Peters, one of our Capitol Hill and campaign reporters, is recapping Season 3 of "House of Cards." If you're binge-watching, read them all. If not, take them in one at a time.
What We're Reading Elsewhere
Justice Antonin Scalia showed his faith in Congress, suggesting it would act to fix the damage done to the Affordable Care Act if the Supreme Court invalidated subsidies for some Americans, Talking Points Memo reports.
National Review Online notes that Senator Rand Paul of Kentucky is unhappy with the "gossipy" news media for tracking his clapping during the congressional speech of the Israeli prime minister, Benjamin Netanyahu.
Jeffrey Toobin of The New Yorker wonders if Chief Justice John G. Roberts Jr. tipped his hand by asking just one question during the oral arguments on Wednesday.
Speaker John A. Boehner has been undercut by the conservative wing of the Republican Party on many occasions, and Politico looks at how he might begin to rethink his job.
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September 18, 2014 Thursday
The Affordable Care Act: Answering the (Easy) Questions
BYLINE: Robb Mandelbaum
SECTION: BUSINESS; smallbusiness
LENGTH: 1071 words
HIGHLIGHT: If you have questions about how the Affordable Care Act will affect your business, post a comment or put them in an email.
Over the next weeks, the Agenda will take a look at the Affordable Care Act and try to answer the questions that small-business owners have about the law and how it will affect them. Some aspects of the law remain very confusing, and others are still not completely settled.
But not all concerns are so complicated to resolve. We've talked to organizations that work with small businesses on health issues and collected several common questions that we present, with their answers. And we will be doing this again. If you have questions about how the Affordable Care Act will affect you, post a comment below, or email them to robb.mandelbaum@nytimes.com.
Q.
When does open enrollment begin for small businesses?
A.
Unlike individuals, small businesses are not limited to buying coverage during a year-end open-enrollment period. They can buy group coverage year-round (when bought before the 15th of the month, the coverage begins on the first day of the next month). However, the Affordable Care Act does create a special end-of-the-year open-enrollment period in the small-group market, from Nov. 15 to Dec. 15, when small businesses can obtain coverage without having to meet the insurer's normal minimum requirement for how many employees must enroll. Typically, carriers require at least 70 percent of a company's employees to participate in the plan in order for the business to get the coverage.
Q.
When will my health insurance have to come into full compliance with the A.C.A.?
A.
Generally speaking, small-group health policies - those enrolling no more than 50 employees - purchased beginning in 2014 have to comply with the market reforms of the Affordable Care Act. But last fall, after an outcry over canceled insurance policies and a rush among small businesses in some parts of the country to renew existing, noncompliant health plans early, the Obama administration announced a "transitional policy" permitting early renewal. Under the current rule, which states can choose to carry out or not, small businesses can continue to renew existing 2013 plans through as late as September 2016. According to America's Health Insurance Plans, an industry group, 36 states permit small groups to renew existing policies; 13 states and Washington, D.C., do not. Separately, so-called grandfathered plans that were in place before the enactment of the Affordable Care Act are not subject to many of its requirements.
Q.
Are the SHOP exchanges finally working? If not now, when?
A.
In theory, small businesses can buy insurance coverage either through the small-business health insurance marketplaces - also known as the SHOP exchanges - or they can buy directly from carriers or brokers. Last fall, the federal government, which is operating the marketplaces in about three-quarters of the states, and many of those states running their own exchanges put aside the small-business exchanges to focus their efforts on the individual exchanges. Federal officials insist that the SHOP exchanges they run will be fully functional by the time the special open enrollment period begins on Nov. 15 - and in late October in Delaware, Illinois, Missouri, New Jersey and Ohio. Many of the troubled state-run exchanges appear to be lagging; California, for one, has not set a date for online enrollment in its SHOP.
Q.
Can I use an insurance broker to enroll in SHOP?
A.
Yes, in most, if not all, states. In fact, for the moment, given all of technical problems SHOP exchanges have had, using a broker remains the easiest way to enroll in a plan through the exchange.
Q.
How do SHOP rates compare to other small group market rates?
A.
When an insurer offers a substantially similar plan both on and off the exchange, there can be no difference in the price. It is unclear whether plans that are not available through the marketplaces will be priced differently. Some insurers have argued that when an exchange allows employees to choose from among a variety of health plans - and eventually, every exchange will have to do this - insurers that do not participate in the exchange will be able to charge less than insurers that do. The thinking is that given a choice, employees will choose their insurance based on how healthy they are, leading to adverse selection. But it is not likely to be a big advantage. And on the other hand, advocates for the exchanges say that transparency and competition will lead to lower prices in those marketplaces. (The 2013 early-renewal plans, which may be cheaper than compliant plans, are not available to companies that don't currently have one.)
Q.
Instead of offering a health plan, can I use pretax dollars to reimburse my employees for buying an individual policy?
A.
Though a handful of companies, most notably Zane Benefits, offer plans that supposedly allow employers to do just that, the consensus among lawyers and other experts contacted by the Agenda is that the Internal Revenue Service believes there is no legal way to reimburse employees for buying their own insurance with pretax dollars. It is, however, perfectly legal to make such reimbursements with post-tax dollars.
Q.
If the small-business health care tax credit exceeds what I owe in taxes, can I get a refund?
A.
The credit is only refundable for nonprofits, and the refund is limited to the amount of income and Medicare tax the nonprofit withholds from workers' wages plus the organization's Medicare liability. However, if your for-profit company's tax credit is more than it owes in taxes, it can apply the excess against the taxes it owed in the prior year and then against the taxes it will owe in any of the next 20 years.
Q.
If I was eligible for the A.C.A. tax credit in previous years but did not claim it, can I claim it now retroactively?
A.
Yes. Generally, a person has three years from the date the tax return was filed to amend it.
Q.
Can I claim the small-employer tax credit in advance of filing my taxes, as with the subsidies for the individual exchange?
A.
The Affordable Care Act provides low- and (some) middle-income people a tax credit to subsidize coverage when they buy it on the individual exchange, which can be paid in advance directly to the insurance carrier rather than claimed the next year when they file their taxes. However, the small-business tax credit is not similarly "advanceable" - as part of the general business credit, it may only be claimed on a tax return.
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July 5, 2012 Thursday
Could States Save by Expanding Medicaid?
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 471 words
HIGHLIGHT: Opting in to the Medicaid provisions under the Affordable Care Act could bring economies to the states in covering care for the indigent, by some calculations.
About a dozen states have indicated that they will opt out of the Medicaid expansion in the Affordable Care Act, with many citing the price tag as the reason. As I wrote in an earlier post, states opting in will get federal subsidies that will cover a vast majority of the cost of expanding coverage to all adults with earnings up to 133 percent of the federal poverty line. But states will need to kick in some money, too.
A few readers, though, argued that other, fuller analyses show that some states might actually save money by covering more people. The study I cited looked at the costs of extending coverage. But it did not estimate the savings that might come along with it.
In 2009, the Council of Economic Advisers put out a report making the case. "Rather than harming the budget situation of the states, health insurance reform would improve it," the economists wrote.
So where do the projected savings come from?
First, state and local governments end up footing much of the bill for uncompensated care. Say you are a low-income, uninsured adult who has an accident, goes to the emergency room and cannot pay out of pocket for your care. The hospital might just absorb the cost for your treatment. (That is why health care providers will push governors very hard for the Medicaid expansion.)
Or the government might. In 2004 and 2005, for instance, the Council of Economic Advisers' report notes, "24 California counties spent $1.61 billion providing care to the uninsured through their Medically Indigent Services Programs."
Second, financing care for the uninsured forces hospitals and doctors to charge the insured higher prices, meaning higher premiums for coverage. (Economists call this a "cost shift.") "Health insurance reform would reduce this 'hidden tax' that individuals with private health insurance pay for uncompensated care for the uninsured," the C.E.A. report argues. State and local governments would benefit by having to pay less to cover their employees.
Third, many states have existing programs that pay for health coverage for the poor. Under the Affordable Care Act - through the Medicaid expansion and the subsidies for families earning 133 to 400 percent of the poverty line - the federal government would absorb much of the cost of those programs.
So how much might states save? The Urban Institute, a nonpartisan research group in Washington, performed a similar, detailed analysis of new costs and cost savings. It ran the numbers for all 50 states and the District of Columbia. (See the chart on Page 12.) It estimates that 21 to 45 states would save money by taking the Medicaid expansion.
How Much Would the Medicaid Expansion Cost Your State?
Medicaid Expansion and Jobs
Health Care: Solidarity vs. Rugged Individualism
Alternatives to the Mandate
How Wider Coverage Affects Health Spending
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January 19, 2016 Tuesday
The Smartest Comments of the Democratic Debate: Readers Weigh In
BYLINE: ANNA NORTH
SECTION: OPINION
LENGTH: 506 words
HIGHLIGHT: Readers praised Bernie Sanders on campaign finance, Hillary Clinton on health care, and Martin O’Malley on “boots on the ground.”
On Sunday, we asked who made the smartest comment during the Democratic presidential debate. Readers were impressed with Bernie Sanders on campaign finance, Hillary Clinton on the Affordable Care Act, Martin O'Malley on "boots on the ground," and more. Below are some of the most popular choices for most intelligent comment of the evening:
"Secretary Clinton - and you're not the only one, so I don't mean to just point the finger at you, you've received over $600,000 in speaking fees from Goldman Sachs in one year.
"I find it very strange that a major financial institution that pays $5 billion in fines for breaking the law, not one of their executives is prosecuted, while kids who smoke marijuana get a jail sentence." - Bernie Sanders
Many readers mentioned part or all of this comment. The discrepancy in punishments "illustrates the 2 tier justice system in the United States," BigCityTap wrote. The senator's remark about Mrs. Clinton's speaking fees "nails it," said Bob Newman. "She is in the pocket of Wall Street."
"The main point in the Congress, it's not the Republicans and Democrats hate each other.
"That's a mythology from the media. The real issue is that Congress is owned by big money and refuses to do what the American people want them to do." - Bernie Sanders
Senator Sanders "beautifully and succinctly pierced the falsehood there's some sort of self-perpetuating and intractable partisan polarization above and beyond the central fact that big money runs both parties and creates the gridlock when its interests are affected," G. Santos wrote.
"The Democratic Party and the United States worked since Harry Truman to get the Affordable Care Act passed.
"We finally have a path to universal health care. We have accomplished so much already. I do not to want see the Republicans repeal it, and I don't to want see us start over again with a contentious debate. I want us to defend and build on the Affordable Care Act and improve it." - Hillary Clinton
"Although Bernie has great ideas, this comment shows Hillary to be more realistic and capable of actually getting things done in the world it is," Claudia the 64-year-old said.
"Even during the Affordable Care Act debate, there was an opportunity to vote for what was called the public option. In other words, people could buy in to Medicare, and even when the Democrats were in charge of the Congress, we couldn't get the votes for that." - Hillary Clinton
This comment "forces proponents of a single player plan to face a hard truth," said Gpshea. "It will never happen!"
" A woman in Burlington, Iowa said to me, 'Governor, when you're with your colleagues, please don't refer to my son who has served two tours of duty in Iraq as a pair of boots on the ground.' Now, we need to be mindful of learning the lessons of the past." - Martin O'Malley
Mr. O'Malley has been criticizing the use of "boots on the ground" for some time. Justin Sayarath, a reader, called his comments on Sunday "an incredible rebuke to common Republican rhetoric about security."
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January 26, 2017 Thursday 00:00 EST
Days Before a Deadline, Trump Team Cancels Ads for Obama Health Plan
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 391 words
HIGHLIGHT: The ads would have run in the final days of the Affordable Care Act open enrollment period, which ends Tuesday. Many consumers tend to sign up just before the deadline.
WASHINGTON - The Trump administration is pulling back advertisements that encourage people to sign up for health insurance under former President Barack Obama's health care law.
The ads were to have run in the next few days of the annual open enrollment period, which ends on Tuesday. In the last few years, large numbers of consumers signed up just before the deadline.
Under the Affordable Care Act, people who go without insurance are subject to tax penalties. But President Trump and Republicans in Congress are determined to repeal the law, including provisions that require most Americans to have insurance.
"The federal government has spent more than $60 million promoting the open enrollment period," a spokesman for the Department of Health and Human Services said Thursday. "We have pulled back roughly $5 million of the final placement in an effort to look for efficiencies where they exist."
However, the department continued to send email messages urging consumers to visit its insurance marketplace at HealthCare.gov.
"Final Deadline," said a typical email sent from the federal marketplace on Thursday. "Our records show that you still need to submit a 2017 application - before the final deadline on January 31. This year, millions of uninsured Americans have incomes that qualify them for reduced monthly costs on high-quality plans. Don't miss your final chance for 2017 health insurance."
Since Nov. 1, more than 11.5 million people have signed up for insurance or had their coverage automatically renewed under the Affordable Care Act, federal officials said this month. More than 8.7 million of those consumers were in states that use HealthCare.gov as an enrollment portal.
Kevin J. Counihan, the former chief executive of the federal insurance exchange, accused the Trump administration of trying to "sabotage open enrollment," and called the action "outrageous."
"We know that more young people enroll during the final days of open enrollment, but they need to be reminded of the January 31 deadline," Mr. Counihan said. "Having health insurance is still law of the land. If the president and Republicans in Congress want to change that, they should come up with a plan and show it to the American people."
Related Articles
After Obama, Some Health Reforms May Prove Lasting
Want to Get Rid of Obamacare? Be Careful What You Wish For
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November 15, 2014 Saturday
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Care Act Supporter Ignites Fury With a Word: 'Stupid'
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 735 words
WASHINGTON -- Three years ago, as President Obama fought for re-election, his team was more than happy to have Jonathan Gruber, a well-known Massachusetts Institute of Technology professor, mouthing off.
Mr. Gruber, a health care expert who helped develop Mitt Romney's health care plan in Massachusetts and later was a consultant for Mr. Obama's Affordable Care Act, was no stranger to the pundit circuit, and repeatedly called attention to the similarities between the two plans -- a politically helpful fact for the Obama 2012 campaign.
''They're the same bill,'' Mr. Gruber declared once, adding an expletive before the word ''bill.''
But now, Mr. Gruber's bluntness is clearly less appreciated by those in the West Wing, thanks to the emergence of a series of videos that show Mr. Gruber calling the American public ''stupid'' and suggesting that the president's health care law passed by fooling Americans about how it works.
''This bill was written in a tortured way to make sure C.B.O. did not score the mandate as taxes,'' Mr. Gruber said in October 2013, referring to the Congressional Budget Office. ''Lack of transparency is a huge political advantage. And basically, call it the 'stupidity of the American voter' or whatever, but basically that was really, really critical to getting the thing to pass.''
The White House was quick to reject Mr. Gruber's comments. Josh Earnest, the president's press secretary, said he disagreed ''vigorously with that assessment,'' and insisted that the ''process associated with the writing and passing and implementing of the Affordable Care Act has been extraordinarily transparent.
Mr. Gruber, an unabashed supporter of the Affordable Care Act, has expressed regret about his comments, telling MSNBC that he was ''speaking off the cuff'' and that he ''spoke inappropriately'' at the academic conference where the video was taken. In an email on Friday, Mr. Gruber declined to comment further.
But the apology has done little to stave off a furious, new Republican assault on the president's health care law, using Mr. Gruber's words as ammunition.
Republican lawmakers, Tea Party activists and conservative pundits have declared Mr. Gruber to be their new truth-teller, using the videos as contemporaneous evidence that their own critiques of the health care law were supported, even by the most ardent backers of the president's efforts.
A Twitter post on Friday from Speaker John A. Boehner said simply: ''Arrogance + deception = #Obamacare.'' A news release from the Tea Party Express said that ''Gruber oozes the elitist arrogance of the Obama administration that thinks their 'superior' Ivy League backgrounds will allow them to pull the wool over our eyes.''
And Reince Priebus, the chairman of the Republican National Committee, said on Twitter on Friday that ''Jonathan Gruber said what most Americans recognize: that #Obamacare was sold on a lie.'' The post linked to a news article with the headline: ''ObamaCare Architect Thinks You're Stupid.''
White House officials rejected the idea that Mr. Gruber was the ''architect'' of the Affordable Care Act. They noted he was never employed by the White House or any federal agency, though he was paid close to $400,000 as a consultant to the Department of Health and Human Services during 2009 and 2010.
But Mr. Gruber had become a high-profile booster of the president's signature domestic achievement and participated in its development. During the contentious debate in Congress, top Democrats frequently cited his analysis of the law's impacts. An invitation to a different October 2013 panel discussion listed him as: ''a key architect of the A.C.A., Dr. Jonathan Gruber.''
Mr. Gruber also made headlines in July when a video surfaced that showed him agreeing that the health care law's tax subsidies were supposed to go only to states that set up their own health exchanges. Thirty-seven states chose not to. That put Mr. Gruber on the opposite side of the White House in a lawsuit that is heading to the Supreme Court.
He said at the time that he ''made a mistake in some 2012 speeches,'' and reaffirmed his belief that the law's tax subsidies are proper and constitutional. But Republicans have decided to believe what they see on the videos.
''The epic search of the Greek philosopher Diogenes for an honest man is finally over,'' Rich Lowry wrote in National Review on Friday. '' His name is Jonathan Gruber.''
URL: http://www.nytimes.com/2014/11/15/us/politics/affordable-care-act-supporter-jonathan-gruber-ignites-fury-with-a-word-stupid.html
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A Turning Point for Health Care -- and Its G.O.P. Opponents
BYLINE: By THEDA SKOCPOL and LAWRENCE R. JACOBS.
Theda Skocpol is a professor of government and sociology at Harvard and director of the Scholars Strategy Network. Lawrence R. Jacobs is a professor of political studies at the University of Minnesota. They are the authors of ''Health Care Reform and American Politics: What Everyone Needs to Know.''
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FOR the second June in four years, the Supreme Court, led by its conservative chief justice, John G. Roberts Jr., has affirmed the legal framework of the Affordable Care Act of 2010 -- the signature achievement of the Obama-era Democratic Party and a national social policy landmark. In so doing, the Roberts court assured the permanent expansion of social protections in America, and also saved the Republican Party from a no-win explosion its own extreme right-wingers tried to ignite.
For health reform, it is now steady as it goes, with wind at its back. The court's June 2012 ruling that the Affordable Care Act was constitutional came at the price of a detour, because that ruling said states could choose whether or not to take federal money to expand their Medicaid programs to cover the near-poor.
However, this new Supreme Court decision, rejecting an ultraright challenge to the nationwide subsidies that allow lower-middle-income Americans to buy affordable private health insurance on state-level exchanges established by the federal government, will speed the already remarkable implementation of health reform. And that progress has been truly rapid by historical standards.
After Social Security was enacted in 1935, it faced a major revamp in 1939. Its taxes were stalled throughout World War II. Social Security remained politically vulnerable until the 1950s and did not become broadly popular or embedded in economic life until reforms under President Richard M. Nixon raised benefits for the poor and the middle class. In contrast, since full implementation of President Obama's health law started in 2014, some 16 million additional Americans have gained health insurance coverage, and the national ''uninsurance rate'' has dropped to under 12 percent from 18 percent.
The Affordable Care Act would have survived even if the Supreme Court had decided King v. Burwell the other way, but insurance markets would have trembled in dozens of states. And millions would have faced threats to new coverage that most consumers report liking. Now sign-ups on the exchanges will continue and many more Republican-led states will decide to take federal money to pay for Medicaid expansion. By the time President Obama leaves the White House in January 2017, as many as 34 million will be covered by the exchanges and Medicaid, and the uninsurance rate could drop below 10 percent.
Of course the partisan clamor is not over. In coming months, many congressional Republicans and presidential contenders will continue to make loud promises about repeal (or ''repeal and replace,'' with replacements never specified), because the ''Obamacare'' label is unpopular with a majority of Republicans. But in 2016 general election campaigns the sound and fury will be muted, because most independents and Democrats do not want repeal or big disruptions and majorities of rank-and-file Republicans favor the tangible benefits. Even if a Republican takes the presidency and that party holds both houses of Congress in 2017, it will not be able to get rid of the insurance regulations in the Affordable Care Act with bare majorities -- and it will not dare abolish coverage for tens of millions of Americans or slash profits for insurance companies and hospitals.
This brings us to the second turning point wrought by the Roberts court ruling: a shift within the Republican Party itself. Again and again over the past century, Republicans and Democrats have gone to partisan war over major social programs -- Medicare and Medicaid as well as Social Security -- and over federal interventions like the Civil Rights Act that promise new gains for minority Americans. The wars over the Affordable Care Act from 2009 have been similarly infused with racial overtones, because the new benefits mostly help Americans of modest means, disproportionately minorities. And the battles have been unusually fierce, because partisan and ideological divisions are now more closely aligned than they were between the 1930s and the 1960s.
But now, Republicans are going to move steadily toward the same sort of grudging adaptation they previously had to make to Social Security and Medicare/Medicaid, with pro-business interests pushing back against ideological purists and Tea Partiers. For Affordable Care Act politics, this shift has been underway in many states for some time, as Republican governors in Ohio, Nevada, Michigan, Indiana and beyond have parried ideological right wingers to find ways to accept the Medicaid expansion that so greatly benefits their white and black poor citizens and the bottom lines of hospitals. Now Chief Justice Roberts has abandoned ultras to his right, upholding subsidies in federal-run exchanges by pointing to the need to avoid throwing insurance markets into turmoil.
As the King ruling came down on Thursday morning, we can be sure that sighs of relief spread among non-Tea Party Republican officeholders and in the halls of the Chamber of Commerce. Sure, the ruling assured the survival of Mr. Obama's main domestic policy achievement, unhappily for Republicans now and in the future. But it also signaled a real setback for right-wing ideological bomb-throwers and gave a boost to Republicans who would like to get on with the business of winning government power to serve practical business interests. In the spirit of Justice Scalia, long live ObamaScotusCare.
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URL: http://www.nytimes.com/2015/06/26/opinion/a-turning-point-for-health-care-and-its-gop-opponents.html
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December 3, 2013 Tuesday
Late Edition - Final
Cost of Health Care Law Is Seen as Decreasing
BYLINE: By ANNIE LOWREY
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LENGTH: 1174 words
WASHINGTON -- The rollout of President Obama's health care law may have deeply disappointed its supporters, but on at least one front, the Affordable Care Act is beating expectations: its cost.
Over the next few years, the government is expected to spend billions of dollars less than originally projected on the law, analysts said, with both the Medicaid expansion and the subsidies for private insurance plans ending up less expensive than anticipated.
Economists broadly agree that the sluggish economy remains the main reason that health spending has grown so slowly for the last half-decade. From 2007 to 2010, per-capita health care spending rose just 1.8 percent annually. Since then, the annual increase has slowed even further, to 1.3 percent. A decade ago, spending was growing at roughly 5 percent a year.
But even though the Affordable Care Act might be more a beneficiary of changes in health care spending than the primary driver of them, the law's provisions to control costs could prove increasingly important as the economy improves, demand for health care increases and spending picks back up.
''It was a trend that was happening; we noticed that trend; we took advantage of that trend,'' said Jason L. Furman, the chairman of the White House's Council of Economic Advisers. ''Some of it was the Affordable Care Act catching up with the private sector, and some of it was pushing the private sector forward.''
Administration officials have pointed to falling hospital readmission rates as one strong sign that cost-control provisions in the Affordable Care Act are working. Also, they noted that a growing number of insurers and health care providers are agreeing to contracts that pay for the quality of care, rather than the quantity, another indication that the law's encouragement on that front is starting to pay dividends.
But those are responsible for only a tiny portion of the slowing rise of health care costs; other changes, like rising deductibles and copays that discourage some people from seeking extra services, play a bigger role, analysts say. Still, the Kaiser Family Foundation, a nonprofit research group, estimates that the weak economy accounts for as much as three-quarters of the slowdown in the growth of spending on health care.
But even if only about a quarter of the savings is because of noneconomic factors, said Larry Levitt, a top official at the Kaiser Family Foundation, ''that's real change in the health system.''
Critics, however, say they see little evidence that the law will lead to significant cost savings.
''These claims are just as groundless as the ones that misled so many Americans to believe they would be able to keep their previous coverage,'' argued Charles Blahous, a former Bush administration official now at the Mercatus Center at George Mason University.
To be sure, the Affordable Care Act will lead to a drastic bump in health spending by the government starting next year, with an estimated nine million Americans signing up for Medicaid and perhaps as many as seven million buying a subsidized health plan through the government exchanges. But economists expect the underlying rate of spending growth to remain low.
And whatever the reasons for the slower growth, taxpayers appear set to reap some benefits.
Already, the Congressional Budget Office has quietly erased hundreds of billions of dollars from its projections. It now estimates that Medicare spending in 2020 will be $137 billion lower than it thought in 2010, a drop of 15 percent; Medicaid spending will be $85 billion, or 16 percent, lower; and private health insurance premiums are expected to be about 9 percent lower.
Some economists say they believe that the Congressional Budget Office might be underestimating the long-term effect of the slowdown, because it expects that spending growth will eventually return to its previous trend line. David M. Cutler, a Harvard economist and former Obama adviser, cautiously suggests that the slower growth might stick around, and if so the savings for the government might be a whopping $750 billion over 10 years, he says.
Whether such improvements will last depends on whether private firms -- nudged along by Washington -- create and retain incentives to keep spending low.
''In the past five decades, there are only two periods when we've been able to sustain low excess health care cost growth for an extended period,'' Mr. Levitt, of the Kaiser foundation, said, referring to the current trend and a period in the 1990s, when the Clinton administration tried and failed at overhauling the health care system. ''There was a sense in the system: 'Something is coming, and we need to get ready for it.' ''
This time may be more durable. Insurance and hospital executives in Massachusetts, Illinois and California, among other places where reforms have gone the furthest, report a consensus that spending growth had become unsustainable, and that expectations that Washington would force changes to the system spurred them to make changes themselves.
Whatever the reasons, the overall slowdown in health costs has led to lower 2014 insurance premiums than analysts anticipated. That means not only cheaper plans for many consumers, but significant savings for the government.
One study by the liberal Center for American Progress, for instance, found that an average individual premium for a plan with relatively high out-of-pocket expenses in the insurance marketplaces is $3,900, about 16 percent lower than the $4,700 expected. If those savings were to stick, the Affordable Care Act would cost about $190 billion less than expected over the course of a decade, the center estimated.
Mr. Levitt pointed out that ''premiums are particularly important for federal costs because of the way the tax credits work.'' An individual purchasing a middle-of-the-road ''silver'' plan, for example, is required to devote a certain fixed proportion of his income to health insurance, with the federal government picking up the rest of the tab. ''The government pays the rest of the premium, so it is more exposed to changes,'' he said.
On top of that, the law might be smaller in scale than originally envisioned. Pervasive problems with the HealthCare.gov site might result in fewer sign-ups than government analysts anticipated, for one. But analysts cautioned that it was too soon to tell how the problems with the website would affect enrollment in private insurance.
On the public front, the 2012 Supreme Court decision allowing states to opt out of the Medicaid expansion slashed the number of people eligible for that program. The White House has stressed that it hopes that all states join the Medicaid expansion, which would help reduce costs for state governments as the federal government picks up most of the bill for the newly covered.
But if the 25 states that have not expanded Medicaid continue to elect not to join in the expansion, federal spending would be about $45 billion lower in 2016, according to calculations by the Urban Institute and the Kaiser Family Foundation.
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September 19, 2012 Wednesday
Happy (Un)constitution(al) Day
BYLINE: LINDA GREENHOUSE
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LENGTH: 1418 words
HIGHLIGHT: Has the Supreme Court's recent decision in the Affordable Care Act case made Constitution Day unconstitutional?
If you regularly hang out around schools or colleges, you might have noticed that this is, by presidential proclamation, Constitution Week, and that Monday was Constitution Day.
At least you might have noticed something special about Monday. That's because back in 2004, Senator Robert Byrd, the late Constitution-toting and -quoting Democrat from West Virginia, got an amendment added to the federal law that designates Sept. 17, the day in 1787 when the delegates in Philadelphia signed the Constitution, as Constitution Day. The Byrd amendment requires that "each educational institution that receives federal funds for a fiscal year shall hold an educational program on the United States Constitution on Sept. 17 of such year for the students served by the educational institution." (If Sept. 17 falls on a weekend or, as it did this year, on a religious holiday, the law permits holding the Constitution Day observance during the preceding or following week.)
The Department of Education's follow-up regulation warns that the amendment "applies to all educational institutions receiving federal funding, not only those receiving federal funding from the Department." In other words, a grant from the National Institutes of Health or the National Endowment for the Humanities also carries the obligation to observe Constitution Day - and all such grants are implicitly at risk of being forfeited by any school, college or university that chooses to spend its Sept. 17 doing something else.
So here's my question: has the Supreme Court's recent decision in the Affordable Care Act case made Constitution Day unconstitutional?
While upholding the health care law's individual mandate, the court invalidated the statute's carrot-and-stick approach to inducing the states to extend Medicaid eligibility to millions of the near-poor. As with Constitution Day, Congress enacted the Medicaid portion of the Affordable Care Act under its "Spending Clause" authority, the power granted Congress by Article I to "pay the debts and provide for the common defense and general welfare of the United States." Federal largesse often comes with strings attached: take it or leave it.
In the Affordable Care Act, the Congressional offer to the states was this: Agree to expand the categories of people whose medical expenses are covered by the federal-state Medicaid program, and the federal government will pay almost all the additional cost. Decline to expand, and risk losing all your existing federal Medicaid money (more than 20 percent of the average state's entire budget.) "It is a gun to the head," Chief Justice John G. Roberts Jr. declared in his opinion. "Congress may use its spending power to create incentives for states to act in accordance with federal policies," the chief justice wrote. "But when pressure turns into compulsion, the legislation runs contrary to our system of federalism." The vote was 7 to 2.
What does this have to do with Constitution Day? In contrast to the Affordable Care Act, the threat of forfeited funds is only implicit and the Byrd amendment lacks an enforcement mechanism for its implied threat. And the potential consequences appear less dire, too. After all, would the government really zero out a major university's federally supported research budget for lack of a Constitution Day program?
Probably not - but, on the other hand, it's also far from clear that the Secretary of Health and Human Services would have actually have tried to recoup the entire federal portion of a recalcitrant state's Medicaid budget. Such a drastic action would have been subject to challenge as "arbitrary and capricious" under the Administrative Procedure Act, leading to perhaps years of litigation. If the penalty provision was "a gun to the head," it's not at all certain that anyone would actually have pulled the trigger.
Consequently, the Medicaid portion of the health care decision seems at least premature, if not gratuitous. It's a mystery why it drew the support of two members of the court's liberal bloc, Justices Stephen G. Breyer and Elena Kagan. Possibly they were providing cover, or at least moral support, to the chief justice on his unsteady journey in the health care case away from his usual allies and out of his comfort zone.
Possibly Justice Kagan harbors a dislike of heavy-handed Spending Clause bargains stemming from her days as dean of Harvard Law School. Along with many other law schools, Harvard supported a suit against the Defense Department over the Solomon Amendment, a law that threatened to withhold federal money from an entire university if any part of the university, such as a law school, failed to provide equal access to military recruiters. In 2006, the Supreme Court rejected the challenge in an 8-0 opinion by Chief Justice Roberts. Quoting the court's language from an earlier Spending Clause case, the chief justice said, "Congress is free to attach reasonable and unambiguous conditions to federal financial assistance that educational institutions are not obligated to accept."
The fact is no one really knows what the impact of the court's new turn on the Spending Clause will be. The Affordable Care Act decision marked the first time the Supreme Court had ever invalidated any law enacted under the Congressional spending power. Justice Ruth Bader Ginsburg, in dissent, called the decision all the more "unsettling" because the case for constitutionality appeared, to her and Justice Sonia Sotomayor, so simple. What, exactly, was the problem with the bargain Congress attempted to strike with the states? Did it simply go too far and threaten too much? If so, when considering the next case, how far would be too far? How close a connection must there be between the desired behavior - honor the Constitution - and the threat - lose your federal money?
Or perhaps the court is telling us that a more fundamental reappraisal is in progress, a turn away from the modern assumption that Congress can pretty much attach any string, as long as the condition itself is not unconstitutional? Certainly the current court has placed Congressional authority under an unfriendly microscope: there were, after all, five votes to strike down the health care law on Commerce Clause grounds. In any event, the court's Spending Clause jurisprudence, once perfectly clear, is now a muddle.
Before the Spending Clause issue arose, Constitution Day came under occasional academic fire for free-speech-related reasons - compelled patriotism in violation of academic freedom, Professor Kent Greenfield of Boston College Law School argued in an Op-Ed essay in The Times a year ago. But First Amendment complaints have never gained traction, because a requirement to observe Constitution Day is far from a requirement to say anything in particular.
An Internet search shows that schools' programming includes everything from a public reading of the Constitution to a classroom debate over the constitutionality of the Byrd amendment itself. Some programs seem perfunctory, and others quite creative, like Purdue University's inclusion of banned and censored books as part of a display intended to get students thinking about the First Amendment. There is a wealth of teaching material online that classroom teachers can use to impart some basic civics to their students, not a bad thing now that civics education has withered. One day a year of civics is surely better than none. (The iCivics Web site, founded by the retired Justice Sandra Day O'Connor as part of her effort to reintroduce civics education into the curriculum, has a particularly robust set of offerings for younger children.)
My friend Sanford Levinson, a law professor at the University of Texas, is well known for his love-hate relationship to the Constitution, which has led him to write such books as "Our Undemocratic Constitution: Where the Constitution Goes Wrong (and How We the People Can Correct It)." I asked Sandy for his thoughts about Constitution Day. He said that when he is asked to speak at a Sept. 17 observance, he starts by raising the question of the Byrd amendment's constitutionality. He then goes on to say that he would be troubled "if schools were required truly to celebrate the Constitution." But, he tells his audience, "my own presence testifies to the possibility that it is enough to discuss it, albeit critically."
What We Think About When We Think About the Court
The Free Speech Puzzle
The Mystery of John Roberts
Hate Speech and Stolen Valor
Romney's Supreme Burden
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February 28, 2017 Tuesday
Late Edition - Final
Trump Concedes Health Overhaul Is a Thorny Task
BYLINE: By ROBERT PEAR and KATE KELLY; Reed Abelson contributed reporting from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1255 words
WASHINGTON -- President Trump, meeting with the nation's governors, conceded Monday that he had not been aware of the complexities of health care policy-making: ''I have to tell you, it's an unbelievably complex subject. Nobody knew that health care could be so complicated.''
The president also suggested that the struggle to replace the Affordable Care Act was creating a legislative logjam that could delay other parts of his political agenda.
Many policy makers had anticipated the intricacies of changing the health care law, and Mr. Trump's demands in the opening days of his administration to simultaneously repeal and replace President Barack Obama's signature domestic achievement made the political calculations far more complicated.
Governors of both parties added still more confusion on Monday when they called for any replacement to cover all the people already benefiting from the landmark law.
''Of course I am concerned,'' said Gov. Brian Sandoval, the Republican governor of Nevada, where about 300,000 people have gained Medicaid coverage. ''I am someone who elected to expand Medicaid. That's been very beneficial to my state, and I want to be sure those individuals can keep their coverage.''
''Governors are all in agreement,'' said Gov. Terry McAuliffe of Virginia, a Democrat who is the chairman of the National Governors Association. ''We do not want one single one of our citizens to lose access to quality health care. We are all unified on that. Actually, we want to expand, so everybody has access to quality health care.''
Mr. Trump brushed aside opinion polls suggesting that the 2010 health law was becoming somewhat more popular. ''People hate it,'' the president said, ''but now they see that the end is coming and they're saying, 'Oh, maybe we love it.' There's nothing to love. It's a disaster, folks.''
Because of the intricate procedures that govern budget legislation and the inherent complexity of health care, Republicans appear unlikely to undo the health law as quickly as they had hoped. Mr. Trump said Congress must tackle the Affordable Care Act before it can overhaul the tax code, also a high priority for Republicans. And those delays could slow work on other priorities like a billion-dollar infrastructure push.
''Statutorily and for budget purposes, as you know, we have to do health care before we do the tax cut,'' Mr. Trump told governors.
After his session with the governors, Mr. Trump met on Monday with executives from health insurance companies. He apparently hopes they will stay in or return to the Affordable Care Act's insurance marketplaces, where more than 10 million people obtained coverage last year.
If the governors' meeting in Washington was supposed to clarify the future of the health law, it fell short. If anything, it exposed deep divisions among state executives, especially Republican leaders.
Gov. Gary R. Herbert of Utah, a Republican, said: ''We did not expand Medicaid. Many states are divided on what the right approach is to take under the Affordable Care Act.'' Some Republican governors, he said, are concerned about the ''sustainability'' of the Medicaid program, which covers more than 70 million low-income people.
And no governor was ready to say publicly that he or she could accept a replacement health law covering fewer people than the Affordable Care Act, which has extended coverage to 20 million Americans.
A bill drafted by House Republicans could cover fewer people. It would roll back the heath law's expansion of Medicaid, eliminate tax penalties for people who do not have health insurance and end taxes imposed by the Affordable Care Act on certain high-income people, insurers, drug companies and manufacturers of medical devices.
To help people buy insurance, if they do not have coverage at work or under a government program, the bill would offer tax credits ranging from $2,000 to $4,000 a year, depending on age. But the credits would not fluctuate with a recipient's income, raising the prospect that insurance might be less affordable for lower-income people. The House Republican bill would also eliminate minimum federal standards for ''essential health benefits,'' and it could require some people with particularly expensive employer-sponsored coverage to pay taxes on some of its value.
The emergence of that draft has produced cries of opposition among Democrats and nervousness in some Republican quarters. Conservatives added their objections on Monday, saying the tax credits could become a permanent entitlement. Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said he could not vote for the bill in its current form because it could create ''a new health insurance entitlement with a Republican stamp on it.''
Mr. Herbert said he could support the Republican proposal to give each state an allotment of federal money with a set amount for each Medicaid beneficiary -- what he and other officials described as a per capita cap. Some experts believe that could be ''the best thing for us to do in Utah,'' Mr. Herbert said.
But Democratic governors generally oppose efforts by congressional Republicans to give each state a fixed allotment for each beneficiary or a lump sum, known as a block grant, for its entire Medicaid program.
''Block grants or per capita caps would throw state finances into disarray'' and shift costs to the states, Democratic governors said in a letter to congressional leaders.
Two House committees may try to vote next week on legislation to repeal the Affordable Care Act and put in place some elements of a replacement. But the disagreements among Republicans, in the Trump administration and on Capitol Hill, suggest a difficult road ahead.
In recent days, some senior White House officials have come to believe that the timetable House Republicans have laid out for the health care overhaul is overly ambitious, said one person who has been briefed on their thinking, given the apparent public opposition to what is known of the plan already and the likelihood that an independent cost-benefit analysis could make it even less attractive to low-income voters.
If the House plan fails, these officials may introduce a White House version of the repeal-and-replace legislation later in the year, with the hope that it will be better received, added the person briefed on the matter.
Gary Cohn, the director of the president's National Economic Council, and his staff have spent significant time studying the Affordable Care Act and its weaknesses. Mr. Cohn and Jared Kushner, the president's son-in-law and a senior adviser, have emerged as skeptics of the plan being developed by House Republicans, said the person briefed on the matter. The White House had no immediate response to a request for comment.
The White House chief of staff, Reince Priebus, is more aligned with the House speaker, Paul D. Ryan, and the secretary of health and human services, Tom Price, who are championing the current repeal-and-replace bill.
Mr. Trump's Treasury secretary, Steven Mnuchin, said as recently as Thursday that the administration hoped to pass tax cuts for both businesses and middle-class Americans in time for Congress's recess in August. But since health care must be addressed first, tax legislation could easily be pushed into 2018, according to members of Congress and administration officials.
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URL: http://www.nytimes.com/2017/02/27/us/politics/trump-concedes-health-law-overhaul-is-unbelievably-complex.html
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July 16, 2013 Tuesday
The Path to Complexity on the Health Care Act
BYLINE: JARED BERNSTEIN
SECTION: BUSINESS; economy
LENGTH: 990 words
HIGHLIGHT: An economist formerly in the Obama administration says the need to accommodate the current employer-based insurance system has made the Affordable Care Act a challenge to carry out.
Jared Bernstein is a senior fellow at the Center on Budget and Policy Priorities in Washington and a former chief economist to Vice President Joseph R. Biden Jr.
In contemplating the one-year delay in the Affordable Care Act's employer penalty, I was reminded that the health care law is an awfully complicated piece of work.
I'm a supporter of the bill, and someone who was working for the administration when health legislation was designed, so let's be clear: the fact that it's complex doesn't mean its implementation is anything like the train wreck that conservative Republicans (and Max Baucus) like to call it.
In fact, as I read the recent report from the Government Accountability Office on setting up the state exchanges - the most complex part of the bill's implementation - I'd say it's proceeding apace despite train wreckers trying to derail it. I suspect most state exchanges will be up and running on Oct. 1 (the federal government is setting up and will operate most of them), and when you consider the magnitude of this challenge amid the blowback and underfunding of the effort, if I'm even close to correct, that will be a very impressive outcome.
But when the White House announced the delay in the employer penalty, a lot of people pointed out that had the United States gone with a single-payer, Medicare-for-all style system, it wouldn't have had to futz around with Rube Goldberg policy structures like that in the illustration below from the Congressional Research Service on the employer penalty.
It's a fair point, and one that took me back to my days of selling the bill out on Pebble Beach, that little strip of land next to the White House where television cameras film administration officials. A typical interview back then (2009-10) would usually involve a reporter asking me to defend the proposed reform and explain why the people should be for it. I cringe to think that I often started out by suggesting that it had the potential to "bend the cost curve" - i.e., slow the unsustainable growth of health costs.
Why cringe? Not because I was wrong - that was a major motivator and the law may already be showing some promise in that critical regard. The cringe is because very few listeners knew what to make of that assertion, and it certainly didn't answer what they really wanted to know, which was, "How is this thing going to affect me and my family?"
That's why being able to say the other line I recall using out there - "If you're happy with your current coverage, this law won't affect you at all" - was so important. And that's also why we're stuck with a lot more complexity than we'd like.
To understand why we are where we are with the Affordable Care Act, it's useful to think about the concept of path dependency, meaning that where you end up is often a function of where you start out. And in the United States, we start out with an employer-based system. Though employers have been shedding coverage, about 58 percent Americans and their families are still covered through their job, down from 68 percent a decade ago (not counting older Americans). Perhaps more importantly, among those with private coverage, a group that the opposition was and is trying to scare about the impact of the law, about 90 percent are covered through their employer.
That's the path we started on, and our judgment was that straying from that path would doom the bill. I suspect we were right. I can assure you that being able to hammer home that line about keeping what you have was very important and comforting for people to hear. Passing the law was in no small part about convincing a majority of passengers on an already rickety boat that they'd be better off if they threw a life preserver to the minority floundering in the water.
That doesn't mean that what we ended up with is optimal. Certainly, the addition of a public, Medicarelike option within the health care exchanges would have been a good compromise, a way to stay on the path but branch off in a more progressive direction. But even without that, objective analysts score the bill as eventually covering millions of people and saving billions of dollars.
Could we have bucked path dependency? Must we continue to accommodate the employer-based system, not to mention the powerful insurance industry deeply embedded in America's uniquely inefficient health care delivery system? Do we really need a bunch of separate health care exchanges?
Well, private insurers supported the law only when it looked as though they'd get to cover a lot more people, with many getting subsidized coverage. Though the coverage offered in the exchanges has to meet national standards, states will continue to regulate the insurers within their borders. (The state accommodations are particularly ironic, because deference to states run by arch conservatives is turning out to be a tough implementation barrier; according to G.A.O., 11 states say they lack "the authority to enforce or are not otherwise enforcing" the insurance market provisions of the Affordable Care Act. It's starting to look like the euro zone out there.)
Perhaps my former colleagues and I lacked imagination, but in the case of health care, with large, risk-averse majorities worried about keeping what they had, powerful industries lining the existent path and a largely reactionary House of Representatives, it's hard to imagine that we could have deviated from path dependency.
So as the implementation season proceeds and new delays and complications pop up, remember the rocky path we started on. I firmly believe that if we can fully carry out the Affordable Care Act - and I think we will - the path will become smoother. And that means the next round of reform will start from a better place.
Putting Off the Employer Mandate
Health Coverage Worthy of a Senator
The New Economics of Part-Time Employment
Confusing the Public on the Affordable Care Act
The Myriad Benefits of a Carbon Tax
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January 4, 2017 Wednesday 00:00 EST
The Parliamentary Tactic That Could Obliterate Obamacare
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1179 words
HIGHLIGHT: Republicans hope to repeal much of the Affordable Care Act through budget reconciliation, an expedited process that has produced some of the nation's most important laws.
WASHINGTON - Republicans hope to repeal major parts of the Affordable Care Act using an expedited procedure known as budget reconciliation.
The process is sometimes called arcane, but it has been used often in the past 35 years to write some of the nation's most important laws. "Reconciliation is probably the most potent budget enforcement tool available to Congress for a large portion of the budget," the Congressional Research Service, a nonpartisan arm of Congress, has said.
Here is a primer.
Q. What is the budget reconciliation process?
A. It is a way for Congress to speed action on legislation that changes taxes or spending, especially spending for entitlement programs like Medicare and Medicaid. Although conceived primarily as a way to reduce federal budget deficits, it has also been used to cut taxes and to create programs that increase spending - changes that can raise deficits.
In the Senate, a reconciliation bill can ordinarily be passed with a simple majority. For other bills, a 60-vote majority is often needed to limit debate and move to a final vote.
Q. Why is it called reconciliation?
A. The term originated in the Congressional Budget and Impoundment Control Act of 1974, which was intended to give Congress more control over the budget process by allowing lawmakers to set overall levels of spending and revenue.
The process begins with a budget blueprint, a resolution that guides Congress but is not presented to the president for a signature or veto. It recommends federal revenue, deficit, debt and spending levels in areas like defense, energy, education and health care.
The resolution may direct one or more committees to develop legislation to achieve specified budgetary results. By adopting these proposals, Congress can change existing laws so that actual revenue and spending are brought into line with - reconciled with - policies in the budget resolution.
Q. How has reconciliation been used?
A. Since 1980, Congress has completed action on 24 budget reconciliation bills. Twenty became law. Four were vetoed.
The Omnibus Budget Reconciliation Act of 1981 was a vehicle for much of the "Reagan revolution." It squeezed savings out of Social Security, Medicare, Medicaid, food stamps, the school lunch program, farm subsidies, student loans, welfare and jobless benefits, among many other programs.
In 1996, Congress reversed six decades of social welfare policy, eliminating the individual entitlement to cash assistance for the nation's poorest children and giving each state a lump sum of federal money with vast discretion over its use. Those changes were made in a reconciliation bill, pushed by Republicans but signed by President Bill Clinton.
Congress reduced deficits with another reconciliation bill, the Balanced Budget Act of 1997. That law also created the Children's Health Insurance Program, primarily for uninsured children in low-income families. On the same day in 1997, Mr. Clinton signed a separate reconciliation bill that cut taxes.
The Bush tax cuts were adopted in reconciliation bills signed by President George W. Bush in 2001 and 2003.
On several occasions, Congress has increased assistance to low-income working families by increasing the earned-income tax credit in reconciliation bills.
Congress also made changes to the Affordable Care Act in a reconciliation bill passed immediately after President Obama signed the health care overhaul in 2010. Later, when Republicans controlled both houses of Congress, they passed a reconciliation bill to eviscerate the Affordable Care Act, but Mr. Obama vetoed the bill in January 2016.
Republicans say that measure will provide a template or starting point for their efforts to undo the health care law this year, with support from President-elect Donald J. Trump, who calls the law "an absolute disaster."
Q. How does the reconciliation process work in the Senate?
A. In the House, leaders of the majority party can usually control what happens if their members stick together. In the Senate, by contrast, one member or a handful of senators can often derail the leaders' plans. The reconciliation process enhances the power of the majority party and its leaders. Senate debate on a reconciliation bill is normally limited to 20 hours, so it cannot be filibustered on the Senate floor.
The Senate has a special rule to prevent abuse of the budget reconciliation process. The rule, named for former Senator Robert C. Byrd, Democrat of West Virginia, generally bars use of the procedure to consider legislation that has no effect on spending, taxes and deficits. The Senate parliamentarian normally decides whether particular provisions violate the Byrd rule, but the Senate can waive the rule with a 60-vote majority.
Q. What does this mean for the Affordable Care Act?
A. Republicans hope to use the fast-track procedure of budget reconciliation to repeal or nullify provisions of the law that affect spending and taxes. They could, for example, eliminate penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.
They could use a reconciliation bill to eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid. And they could use it to repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.
Republicans could also repeal a number of taxes and fees imposed on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices: tax increases that help offset the cost of the insurance coverage expansions.
Those provisions were all rolled back in the reconciliation bill Mr. Obama vetoed last January. That bill did not touch insurance market standards established in the Affordable Care Act, which do not directly cost the government money or raise taxes. The standards stipulate, for example, that insurers cannot deny coverage or charge higher premiums because of a person's pre-existing conditions. Insurers must allow parents to keep children on their policies until the age of 26, and they cannot charge women higher rates than men, as they often did in the past.
Such provisions are politically popular, but it is not clear how they could remain in force without the coverage expansions that help insurers afford such regulations. Without an effective requirement for people to carry insurance, and without subsidies, supporters of the health law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.
Democrats say they will fight to preserve the law after Mr. Obama leaves office. Recent history shows that lobbying and public pressure can sometimes make a difference, altering the votes of individual lawmakers and changing the contents of a reconciliation bill.
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After Obama, Some Health Reforms May Prove Lasting
Job No. 1 for a New Congress? Undoing Obama's Health Law
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April 25, 2014 Friday
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Democratic Candidates Grow More Vocal in Supporting Health Law
BYLINE: By ASHLEY PARKER
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 950 words
WASHINGTON -- Representative Allyson Y. Schwartz, Democrat of Pennsylvania, did the seemingly unthinkable on Tuesday: She ran a television ad expressing how proud she was of President Obama's signature health care law.
''I worked with President Obama on the Affordable Care Act and getting health coverage to all Americans,'' Ms. Schwartz, who is running for governor, said in the 30-second commercial. ''It was my legislation that said insurance companies can no longer deny coverage for kids with pre-existing conditions.''
Ms. Schwartz -- whose campaign paid more than $500,000 to show the ad in the Philadelphia and Pittsburgh media markets -- is one of a small number of Democratic candidates offering a wholly supportive message on a law Republicans want to repeal. (In Ms. Schwartz's case, she is trying to gain traction in her state's Democratic primary and hopes her support of the law will help with the party's base, as well as in the general election.)
So far, 76 percent of all Republican-sponsored general election spots in House and Senate races this year have attacked the Affordable Care Act, making the law the most mentioned issue in such ads, according to Kantar Media/CMAG, which tracks political advertising. But Democrats, who this cycle have run largely on a ''fix, don't repeal'' strategy concerning the law, are now gingerly experimenting, mostly in primaries and through outside groups, with ads that endorse the law and also say what could be lost if Republicans repeal it.
''There's definitely a shift on the Affordable Care Act from defense to offense,'' said Representative Steve Israel of New York, chairman of the Democratic Congressional Campaign Committee. ''Republicans have this political fantasy about repeal, but the facts of repeal are hard for people to swallow.''
For some Democrats, the strategy is two-pronged -- to continue talking about their plans to fix and improve the law, and to highlight the negative consequences for Americans if it is repealed outright.
In Alaska, an outside group is running a commercial supporting the re-election bid of Senator Mark Begich, a Democrat, that features a breast cancer survivor running on the state's snowy tundra as she talks about how Mr. Begich ''fought the insurance companies so that we no longer have to.'' In West Virginia, House Majority PAC recently bolstered Representative Nick J. Rahall II, considered a vulnerable Democrat, with an ad that talks about the protections that could be lost -- such as the so-called black lung benefits for coal miners.
And a radio spot by Elisabeth Jensen, who is running in the Democratic primary in Kentucky to challenge Representative Andy Barr, criticizes Mr. Barr for repeatedly voting to repeal the Affordable Care Act. ''We really have a good thing, and I think it's time Democrats start standing up for it,'' Ms. Jensen said in a phone interview, noting that Kentucky's state health exchange was one of the more successful in the nation (she also said she was considering TV ads supporting the law as soon as she raised more money).
Charlie Crist, a Republican-turned-Democrat who is running to get his old job back as the governor of Florida, even called the health care law ''great'' several times at a luncheon this week.
Andrea Bozek, a spokeswoman for the National Republican Congressional Committee, said the recent spate of ads Democrats were running in support of the law would ''be great for Republicans'' in November.
''We're going to be able to take those ads that they're wasting their money on, and use that footage and put it in our attack ads this fall,'' Ms. Bozek said.
Stuart Stevens, Mitt Romney's chief strategist in the 2012 presidential campaign, said the fact that some of these ads did not mention the Affordable Care Act by name was an indication of the challenges Democrats still face.
''If there's a defense of Obamacare that doesn't mention Obamacare, that's not exactly a real defense,'' he said. ''It's sort of like your parents trying to get you to eat vegetables by saying they're not vegetables.''
At the White House, there is no sense of a sweeping change in tone among Democrats.
''I wouldn't make the case there's been a seismic shift of the politics around the Affordable Care Act,'' said Josh Earnest, a White House spokesman. ''But what I think is happening is those candidates who are inclined to capitalize on some of the more prominent, positive impacts of the law can now do so on much stronger ground. We have been saying that good policy eventually leads to good politics, and this is an early -- but strong -- indication of that.''
With the botched rollout of the law's website receding, and with several pieces of good news -- the higher-than-expected number of sign-ups, with eight million people enrolled for health insurance on the new marketplaces -- Democrats say they see an opportunity for their candidates to marshal evidence in support of the law. A recent New York Times Upshot/Kaiser Family Foundation poll found that a majority of people in three Southern states (Kentucky, Louisiana and North Carolina) would rather Congress improve the law than repeal and replace it.
Last month, one slide in a 17-page PowerPoint presentation the White House made to Senate Democrats was titled ''Peace of Mind Guarantees,'' and included positive results of the law -- ''women can no longer be charged higher premiums just because they are women,'' for instance -- that Democrats could use on the stump or in their ads.
It is a theme Ms. Schwartz has adopted. ''I worked on it and helped pass it, and I'm proud of it, and I want to talk about it,'' she said in an interview. ''I do think it's a winner among the people of Pennsylvania.''
URL: http://www.nytimes.com/2014/04/25/us/politics/democratic-candidates-grow-more-vocal-in-supporting-health-law.html
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GRAPHIC: PHOTOS: Left, Representative Allyson Y. Schwartz, a Democrat running for Pennsylvania governor, in an ad saying how proud she is of the health law. Right, an ad in West Virginia stressed that so-called black lung benefits for miners could be lost if the law is repealed.
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October 26, 2016 Wednesday
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Growing Costs of Health Law Pose a Late Test
BYLINE: By PATRICK HEALY and ABBY GOODNOUGH; Nick Corasaniti and Megan Thee-Brenan contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1392 words
Donald J. Trump, desperate for a winning political issue in the final two weeks of the presidential race, fiercely attacked Hillary Clinton on Tuesday over sharp premium increases that will hit some Americans covered under the Affordable Care Act.
''The rates are going through the sky,'' Mr. Trump said at a rally in Sanford, Fla., referring to double-digit increases in battleground states like North Carolina and Iowa.
''Repealing Obamacare and stopping Hillary's health care takeover is one of the single most important reasons that we must win on Nov. 8.''
But Mr. Trump almost instantly undercut his new offensive with his tendency to muddy his central message. He appeared uncertain at one point about how the health care law worked for his own employees, and then spent only four minutes on the rate increases during a 45-minute speech at the rally.
The Department of Health and Human Services reported Monday that premiums for midlevel health plans on the health law's federal insurance exchange would rise by an average of 25 percent, but in some cities and states, increases will be considerably higher. Mr. Trump asserted that rates would go up ''60, 70, 80, 90 percent'' -- apparently referring to exorbitant jumps in select markets.
Those increases, however, will be cushioned for most people on the exchanges by government subsidies that will rise with the premiums.
Mrs. Clinton, in an interview with a Miami radio station on Tuesday, said she was committed to making ''changes to fix problems'' in the health law while reaffirming her alliance with President Obama, whose diverse coalition of supporters is crucial to her electoral strategy.
The higher premiums pose an 11th-hour test for Mr. Trump and Mrs. Clinton in a campaign that has scarcely revolved around policy issues. Mr. Trump has repeatedly struggled to prosecute a political case against Mrs. Clinton, most notably failing to focus in a sustained way this summer on the scathing F.B.I. report on her State Department email.
Whether he can make Mrs. Clinton pay a political price for supporting the Affordable Care Act, and more broadly for championing President Obama's priorities, will reveal his ability to turn a policy issue into a political weapon at this late stage of the race.
''It needs to be the principal message; you can't dilute the attack by all the other stuff Trump talks about every day,'' said Ed Rollins, a veteran Republican strategist.
For Mrs. Clinton, the problems with the Affordable Care Act could force a reckoning that she had hoped to avoid. As a candidate, she has linked herself more closely to Mr. Obama than any nominee has done with a sitting president in modern times, defending his economic record and praising him for pushing the health law through a sharply divided Congress.
Republicans had hoped that their nominee would force Mrs. Clinton to own the health care law, politically speaking, or at least be forced to defend it, but she has mostly skated past its flaws in cost and coverage. A Kaiser Family Foundation poll in September found that roughly six in 10 adults said the candidates' plans to address of cost of their health insurance premiums and deductibles would be very important to their vote for president.
Still, parts of the health law are politically popular. The United States has the lowest percentage of uninsured citizens in its history. Because of the Affordable Care Act, insurers cannot deny coverage for a pre-existing medical condition and cannot cap lifetime coverage. Children can remain on their parents' policies until age 26.
Mrs. Clinton says she wants to improve the law by increasing the subsidies that help cover premiums and allowing more Americans to receive government help.
She also wants to add a government-run insurance option, which she says would increase competition and choice in the marketplaces created under the health law. And she has proposed allowing people younger than 65 to buy in to Medicare.
In her Miami radio interview, Mrs. Clinton said of those insured by the law, ''Look, this is a major step forward: 20 million people.''
She added that ''I'm sure you noticed, predominantly working people, African-American, Latino people now have access to insurance, but the costs have gone up too much. So we're going to really tackle that.''
Mr. Trump says he wants to repeal the health law and take more of a free-market approach. He would reduce federal regulation and coverage requirements so insurance would cost -- and cover -- less. He would not require Americans to have health insurance, as the Affordable Care Act does.
''By failing to denounce it, Hillary Clinton owns it,'' Kellyanne Conway, Mr. Trump's campaign manager, said of the health care act in an interview on Tuesday.
That political attack will not necessarily resonate.
While the problems in the individual insurance market are real, they affect only a small fraction of Americans. In 2015, 49 percent of Americans got health insurance through a job, 34 percent got it through Medicare or Medicaid, and 7 percent got it through the individual market, according to the Kaiser Family Foundation, a nonpartisan research group.
Of the 10.5 million Americans who get health insurance through the Affordable Care Act marketplaces, about 85 percent receive income-based subsidies to defray the cost.
That leaves seven million people buying insurance on their own without subsidies, because their income is too high or they are not aware of the option -- a significant number but not a huge voting base.
Even for those seven million, the effect will range widely. For a 27-year-old in the battleground states of Ohio and New Hampshire, the average monthly premium for a benchmark plan will rise next year by only 2 percent. In Indiana, where the health care law is helping to shape a key Senate race, the average monthly premium for a benchmark plan will actually decrease, by 3 percent.
But in tightly contested North Carolina, it will rise by 40 percent, to $446 from $319. In Iowa, it will rise by 25 percent, to $308 from $246. And the biggest increase will hit the new battleground of Arizona, where premiums will rise 116 percent.
Mr. Trump stumbled out of the gate on Tuesday as he sought to bash the health law. Speaking to scores of his own workers at his Miami golf course, he said that ''all of my employees are having a tremendous problem with Obamacare'' -- suggesting that his company doesn't provide health insurance or else misunderstanding the program. Moments later, he said of his employees, ''They're not worried about their health care because we take great care of people.''
After finishing, Mr. Trump left it to the resort's general manager to talk to reporters about the confusion and confirm that only a few employees may be insured through the Affordable Care Act.
The problems with the health law have been apparent for some time. Neither the law's subsidies nor its penalties for those who refuse to buy insurance have persuaded enough young, healthy people to go into the insurance marketplaces it created. That has left a customer pool in some parts of the country that is too sick and too small. Because so many marketplace customers have needed expensive medical care, some insurers have spent more on claims than they have earned in premiums.
Another reason for the volatility in the marketplaces is political. The Obama administration, blocked by Republican opponents in Congress, has paid out only a fraction of the $2.5 billion it owes insurers under a provision of the health law that was supposed to protect them from unexpectedly large losses during their first few years in the marketplaces. Several insurers cited the minimal payments as one of the main reasons they raised rates or abandoned the marketplaces.
Republicans zeroed in on the Phoenix rate increase to press their political case.
''I can't imagine Arizona voting for Democrats,'' Hugh Hewitt, a conservative talk show host, said during an interview with Mr. Trump's running mate, Gov. Mike Pence of Indiana.
''Yeah, it really is incredible,'' Mr. Pence said. ''Isn't it amazing that you had Barack Obama a week ago literally celebrating the launch of Obamacare, and then we find out from his own H.H.S. in the last 24 hours that premiums are going to go up 25 percent across the board?''
URL: http://www.nytimes.com/2016/10/26/us/politics/hillary-clinton-donald-trump-affordable-care-act.html
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GRAPHIC: PHOTO: Hillary Clinton campaigned in Coconut Creek, Fla., on Tuesday. The problems with the Affordable Care Act could force a reckoning that she had hoped to avoid. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A19)
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September 25, 2013 Wednesday
Medicare's Lessons for the Affordable Care Act
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 642 words
HIGHLIGHT: The creation of Medicare in the 1960s may offer some insights for how the Affordable Care Act will go into effect, but the demographics of those eligible are quite different, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Next week will not be the first time that the federal government has introduced a new, subsidized health insurance program for millions of people. The introduction of the Medicare program a half-century ago provides some indicators of how the Affordable Care Act's new health insurance marketplaces might evolve after they open on Tuesday.
The Affordable Care Act creates health insurance marketplaces or "exchanges" where families and individuals can purchase private health insurance. Most people currently without insurance will be eligible for assistance with their health insurance premiums, capping their payments at 2 to 10 percent of their household income.
The federal budget, and perhaps also the health of millions of people, depends on how many people take advantage of the new program.
People will not be forced to take part in the exchanges, but those who do not will be assessed a small penalty for not being insured (whichever is greater, 1 percent of household income, or $95 per person) that would appear on their federal tax return when they file in early 2015. Doctors and hospitals may also insist that their uninsured patients join the exchanges rather than requesting "free" care.
On July 1, 1966, Americans 65 and older were first eligible to take part in the new Medicare health insurance program, in which the federal government paid much of the cost. Previously, almost half of the elderly had no health insurance.
By the end of 1966, 19 million people were enrolled in Medicare, almost exactly the same as the number of Americans who were 65 or older at the time. The first full year of the program was 1967.
Those were the days before rapid Internet communication, and a number of elderly people lived in rural areas away from major hospitals and medical centers. In the current environment, the health insurance programs coming on line next week might spread even more quickly than Medicare did.
On the other hand, the elderly population may have been easier to reach than today's uninsured nonelderly people, because the elderly had already been participating in the Social Security pension program. Also, the new health insurance exchanges will have staggered enrollment periods (about two months near the end of each calendar year), whereas elderly are enrolling in Medicare all year long (a person's Medicare enrollment period is seven months based on the date he or she turns 65).
The Medicare-eligible population - essentially people 65 and over - is also less policy-sensitive than the population eligible for the new exchange plans. People over 65 are created by waiting for 64-year-olds to have another birthday, and there's not much policy and economic events can do about that. But people eligible for the new exchange subsidies must be in families with income of 100 to 400 percent of the poverty line and must not have a job that offers affordable coverage - conditions that economic change or policies might affect.
Incentives and economic events are likely to increase the number of people eligible for the exchange subsidies, but those economic behaviors may take some time to play out. For that reason, participation in the exchange plans may continue to increase significantly even after 2015, when the program will have been two years old.
Based on the Medicare experience, I expect more than 15 million people to enroll in the new exchange plans by 2015, with millions more joining thereafter as the economy adjusts to the new law.
The Wyden-Ryan Plan: Deja Vu All Over Again
How to Gut Obamacare
Obamacare vs. Romneycare: The Labor Impact
The Economics of the Affordable Care Act
Health Care Inflation and the Arithmetic of Labor Taxes
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January 16, 2017 Monday 00:00 EST
Fear Spurs Support for Health Law as Republicans Work to Repeal It
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1638 words
HIGHLIGHT: Thousands of people are speaking out in support of the Affordable Care Act by sharing testimonials with Congress and holding rallies across the country.
Correction Appended
WASHINGTON - President-elect Donald J. Trump and congressional Republicans appear to have accomplished a feat that President Obama, with all the power at his disposal, could not in the past seven years: They have galvanized outspoken support for the Affordable Care Act.
People who benefit from the law are flooding Congress with testimonials. Angry consumers are confronting Republican lawmakers. And Democrats who saw the law as a political liability in recent elections have suddenly found their voice, proudly defending the law now that it is in trouble.
Thousands of people across the country held rallies over the weekend to save the health care law, which Republicans moved last week to repeal with a first but crucial legislative step. A widely circulated video showed Representative Mike Coffman, Republican of Colorado, eluding constituents who had wanted to meet with him to express their concerns on Saturday at a community event in Aurora, Colo. Rallies on Sunday to save the health law drew robust crowds around the country.
"We are here today - thousands strong in Boston, and at more rallies all across this country - because we will make our voices heard," Senator Elizabeth Warren, Democrat of Massachusetts, told a crowd outside Faneuil Hall in Boston. "If Republicans try to rip health care out of the hands of millions of Americans, we will fight them every step of the way."
And progressive groups are planning a two-month cross-country bus tour to fight the repeal effort, starting Tuesday.
With their quick strike on the law in the first days of the new Congress, Republicans had hoped to begin the repeal process before a backlash could develop or opposition could be organized. But congressional Republicans are at risk of losing the message war, especially since they are fighting on two fronts.
On one side, the president-elect has repeatedly lobbed disruptive demands at them, such as his insistence that they prepare a replacement health bill almost immediately. To that, he added a new promise over the weekend: that the Republican version would provide "insurance for everybody."
On the other front, Democratic lawmakers have taken to quoting grateful constituents to personalize what can be an arcane legislative fight: Bryce in Seattle; Randy in Rhinelander, Wis.; Nicole in Hockessin, Del.; and many more. The focus of public attention appears to be shifting from the well-documented defects of the health care law to the plaintive pleas of people terrified of losing insurance if the law is repealed.
"I want to thank President Obama from the bottom of my heart because I would be dead if it weren't for him," Jeff Jeans, a small-business man from Sedona, Ariz., who described himself as a lifelong Republican, told Speaker Paul D. Ryan on Thursday at a town-hall-style meeting televised on CNN.
Republicans acknowledge their constituents' concerns, but they say supporters of the health law are manufacturing them. Representative Rob Woodall, Republican of Georgia, blamed Democrats for "amping up anxiety" with "fear mongering."
"The anxiety is real," Mr. Woodall said, "but it's real based on the failures of the president's health care law."
Republicans will soon face a new challenge: maintaining anger at "Obamacare" without Mr. Obama in the White House to stir their passions.
Regardless of its provenance, the law's support has until now received less attention. Appearing on the NBC News program "Meet the Press" five days after Mr. Obama signed the Affordable Care Act in 2010, Senator Chuck Schumer, Democrat of New York, predicted that as people learned about the law, "it's going to become more and more popular."
Around 20 million Americans have gained coverage through the Affordable Care Act's online insurance marketplaces or through its expansion of Medicaid, and enrollment has continued to grow. About11.5 million people have signed up for marketplace plans or had their coverage automatically renewed for this year, nearly 300,000 more than at this time last year, the Obama administration said this month.
But the popularity bounce never came. Public opinion remains deeply divided, with the law no more popular today than when it was passed. In December, according to a monthly tracking poll by the Kaiser Family Foundation, 46 percent of Americans had unfavorable views of the law, up from 40 percent in April 2010. The share with favorable views slipped to 43 percent, from 46 percent in April 2010.
"In the short term, the A.C.A. has been a political disaster for President Obama and the Democrats," Dr. Ezekiel J. Emanuel, a health policy adviser in the Obama White House from 2009 to 2011, said in a 2014 book.
As Congress took a first step last week toward rolling back Mr. Obama's signature domestic achievement, Mr. Trump celebrated. "The 'Unaffordable' Care Act will soon be history!" he said on Twitter.
Some Democrats distanced themselves from the Obama administration after HealthCare.gov crashed on its debut in 2013. More recently, with premiums soaring and insurers defecting from the Affordable Care Act marketplace in many states, Democrats were hard put to defend the law, which was passed without any Republican votes.
But as Mr. Trump and congressional Republicans race to repeal the law, Democrats are taking a more aggressive stance.
Senator Debbie Stabenow, Democrat of Michigan, told the story of Sonja L. Podjan, a 55-year-old blueberry farmer in Watervliet, Mich., who was in pain for several years until she got insurance under the Affordable Care Act, which covered the cost of surgery to repair a severe tear in the meniscus of her right knee.
In an interview, Ms. Podjan said she "started freaking out" after the election and sent an email to Ms. Stabenow. She said she was "flabbergasted" when she heard back from the senator's office.
Ms. Podjan said that the premium for an insurance policy covering her and her husband was about $1,000 a month, but that they paid just $62 after receiving government subsidies provided under the law.
"I am scared to death we will lose our insurance, and what happens then?" said Ms. Podjan, who reported that she and her husband had medical expenses totaling $41,000 in the past two years.
Senator Tom Udall, Democrat of New Mexico, told the story of a constituent, Kevin Kargacin, whose daughter Amber takes drugs costing more than $60,000 a year for multiple sclerosis. "Kevin is scared because the cost of treating Amber's disease is so high," Mr. Udall said.
In an interview, Mr. Kargacin said he wrote to Mr. Udall because "we are terrified that without the Affordable Care Act, Amber could be denied insurance or run into lifetime caps on expenditures for her treatment."
Senator Amy Klobuchar, Democrat of Minnesota, said: "Many Minnesotans have contacted me in the last few months, frightened about the future of their health care coverage. I heard from a man in Orono. His wife was diagnosed with cancer this year. On top of everything his family is now dealing with, he is terrified that his family will lose coverage if there is a repeal."
Whether such concerns reflect a change in public opinion is difficult to say. Over the past six years, Republicans have collected stories from hundreds of constituents complaining that their insurance policies were canceled, their premiums have shot up and their deductibles are so high that the insurance is nearly worthless.
"Scott from Hickory has had his health insurance canceled three times now, disrupting his continuity of care," said Representative Virginia Foxx, Republican of North Carolina. "Patricia from Kernersville now has a whopping $6,550 deductible."
Representative Pat Tiberi, Republican of Ohio, reported that a constituent named Kimberly had difficulty obtaining treatment for a brain tumor because, she said, "virtually no doctors take the marketplace insurance."
The differing accounts are not necessarily in contradiction. Some people have benefited from the law while others have seen their coverage disrupted.
Republicans said the Obama administration had been slow to recognize and acknowledge problems with the Affordable Care Act. Administration officials said insurance rate increases of 25 percent or more were not a significant problem because low-income people could get subsidies to help defray the cost - even though millions of people buying insurance on their own do not receive subsidies.
The administration insisted that insurance markets were "stable and vibrant" even as large insurers pulled out of Affordable Care Act exchanges where they were losing hundreds of millions of dollars. In 2015, the administration said that "claims data show healthier consumers" in the exchanges, but some insurers disputed that assessment, saying they had not seen an influx of healthy people to help cover the costs of sick people.
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Correction: January 16, 2017, Monday
This article has been revised to reflect the following correction: Because of an editing error, an earlier version of this article misstated the day on which the town-hall-style meeting with Speaker Paul D. Ryan was held. It was Thursday, not Friday.
PHOTOS: Rallies in protest of efforts to repeal the health law were held across the country over the weekend in places like Denver, left; Warren, Mich., center; and Midtown Manhattan near Trump Tower. (PHOTOGRAPHS BY CHRIS SCHNEIDER/AGENCE FRANCE-PRESSE - GETTY IMAGES; ROBIN BUCKSON/DETROIT NEWS, VIA ASSOCIATED PRESS; DREW ANGERER/GETTY IMAGES)
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February 22, 2015 Sunday
Late Edition - Final
Flood of Briefs on the Health Care Law's Subsidies Hits the Supreme Court
BYLINE: By ROBERT PEAR
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LENGTH: 1246 words
WASHINGTON -- Liberal groups are emphasizing states' rights, a theme calculated to appeal to conservative Supreme Court justices. The insurance industry, once a foe, has come to the aid of President Obama.
Conservatives are mining legislative history to discern the intent of Democrats who wrote the Affordable Care Act. And those Democrats are firing back, saying they know exactly what their intent was: to provide affordable health insurance to all Americans.
Eliminating subsidies in the federal insurance exchange ''would be a disaster,'' the American Hospital Association argues. The ranks of the uninsured would grow, it says, and ''many more people will get sick, go bankrupt or die.''
Such arguments are set forth in legal briefs flooding into the nation's highest court ahead of oral arguments March 4 that will challenge the payment of subsidies for health insurance in more than 30 states and could determine the fate of the health care law. The case, King v. Burwell, was once seen as a long-shot attempt by conservatives to gut the law by picking out one pivotal phrase in its hundreds of pages that they say the Obama administration has flagrantly misinterpreted.
The law, signed by President Obama in March 2010, says subsidies are available to people buying insurance on an exchange ''established by the state.'' The plaintiffs say those words mean that subsidies are not available through the federal HealthCare.gov insurance exchange, which serves about three dozen states with two-thirds of the nation's population.
Since the Supreme Court accepted the case for argument, the plaintiffs are long shots no more, and a major legal battle has erupted among outside forces armed only with amicus curiae, or friend of the court, briefs. Critics of the law coordinated their briefs, as did supporters of the Obama administration, to a lesser degree.
And those dueling briefs could have consequences, said Anthony J. Franze, a lawyer at Arnold & Porter in Washington who systematically reviews amicus curiae briefs filed with the Supreme Court.
''Justices are paying more attention to amicus briefs and regularly cite them and rely on them in their opinions,'' Mr. Franze said.
The plaintiffs in the case, four Virginia residents, say the Affordable Care Act authorizes tax credits for low- and moderate-income people only in states that established their own insurance exchanges. Congress, they say, offered the subsidies as a way to induce states to set up exchanges.
But Virginia and 21 other states reject that argument. To succeed with such an inducement, they say, Congress would have needed to inform the states that the law included the enticement of subsidies only for those that built their own exchanges. It never did so.
''States selected among exchange options without clear notice that the choice could harm their citizens and disrupt their insurance markets,'' the states said in their brief. Indeed, they said, states as diverse as Delaware, Illinois, New Hampshire and Virginia assumed that premium tax credits would be available to their citizens through the federal exchange. To deny those credits now, those states added, ''would destroy state insurance markets and render the Affordable Care Act unworkable.''
A set of states dominated by Republicans -- Alabama, Georgia, Nebraska, Oklahoma, South Carolina and West Virginia -- argue just as vociferously that they were well aware of the inducement.
The arrangement, they said, ''came as no surprise to the states'' because Congress had pursued a similar approach in many social welfare programs, using money as an incentive for states to carry out federal policies.
The briefs address virtually every conceivable argument that has come up in King v. Burwell.
The chief lobby for the insurance industry, America's Health Insurance Plans, described the subsidies as one of ''three interconnected provisions'' of the Affordable Care Act. The other provisions require most Americans to have insurance and prohibit insurers from denying coverage to sick people or charging them more.
If the Supreme Court eliminates the subsidies in states using the federal exchange, the group said, ''it would leave consumers in those states with a more unstable market and far higher costs than if the Affordable Care Act had not been enacted.''
Without subsidies, the insurers said, ''young and healthy individuals would opt out of the exchanges,'' driving up premiums for the remaining consumers, including those who do not receive subsidies.
While most of the insurers' brief is helpful to the Obama administration, they made one argument that may irk the White House: that consumers need the subsidies because other provisions of the Affordable Care Act, including benefit mandates and premium taxes, have raised the cost of insurance.
Another important brief supporting the administration was filed by one of the nation's largest hospital chains, HCA, also known as the Hospital Corporation of America.
''The Affordable Care Act is functioning as intended,'' HCA said, and the plaintiffs' interpretation of the law would produce consequences ''so absurd that Congress could not possibly have intended them.''
Citing its own experience, HCA said that after patients obtained insurance through the exchanges, they were less likely to use emergency rooms, more likely to receive proper care in outpatient clinics, and more likely to pay their share of hospital bills.
Prof. William N. Eskridge Jr. of Yale Law School, an expert on statutory interpretation, offered an argument calculated to appeal to conservatives like Justice Antonin Scalia who focus on the text of the law and scorn the use of legislative history as a guide to its meaning.
Even judges who exalt the text must not read one short phrase, ''established by the state,'' in a vacuum, Mr. Eskridge wrote in a brief joined by four other scholars.
''A statutory phrase that has one apparent meaning when read in isolation may have a different meaning when read in the context of the statute as a whole,'' Mr. Eskridge said, noting that the law declared its purpose to be providing affordable coverage ''for all Americans,'' with the emphasis on ''all.''
By contrast, Republican members of Congress, led by Senator John Cornyn of Texas, argue that the text of the health care law is ''perfectly clear.'' Congress, they say, deliberately chose to make subsidies available only for insurance bought through state exchanges.
In providing tax credits through the federal exchange, they say, the Obama administration has usurped the authority of Congress and tried to accomplish through an aggressive interpretation of the law ''what it could not accomplish in the halls of Congress.''
Democrats who helped write the law, including Representative Nancy Pelosi of California, the House minority leader, and Senator Harry Reid of Nevada, the Senate minority leader, told the court that they were much better qualified to explain its meaning.
''Congress never intended, or suggested to the states, that tax credits would only be available to individuals who purchased insurance on state-run exchanges,'' the Democrats' brief said.
The brief, filed also on behalf of more than 100 state legislators, added that state officials ''never understood the tax credits to be limited to state-run exchanges.''
Thus, it concluded, the plaintiffs' argument ''makes no sense in light of the text, history and purpose of the statute.''
URL: http://www.nytimes.com/2015/02/22/us/flood-of-briefs-on-the-health-care-laws-subsidies-hits-the-supreme-court.html
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House Expected to Follow Senate's Lead on Rush to Repeal Health Law
BYLINE: By THOMAS KAPLAN, ROBERT PEAR and EMMARIE HUETTEMAN
SECTION: Section A; Column 0; National Desk; Pg. 21
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WASHINGTON -- The House is expected to give final approval on Friday to a measure that would allow Republicans to speedily gut the Affordable Care Act with no threat of a Senate filibuster, a move that would thrust the question of what health law would come next front and center even before President-elect Donald J. Trump takes office.
The House vote would come after the Senate narrowly approved the same measure, a budget blueprint, early Thursday morning. Americans woke up Thursday to the realization that a Republican Congress was serious about repealing President Obama's signature domestic achievement -- a move that could leave 20 million Americans unsure of their health coverage and millions more wondering if protections offered by the Affordable Care Act could soon be taken away.
''This is a critical step forward, the first step toward bringing relief from this failed law,'' Senator Mitch McConnell of Kentucky, the majority leader, said.
Democrats said the rush to repeal was the height of legislative irresponsibility and would endanger the health of millions.
''For the life of me, I can't understand the need to take health care away from people, and why in the world anybody would even contemplate doing that without something to replace it,'' said Representative Louise M. Slaughter of New York. ''Just snatching it out from under them and it's gone. I think that there's going to be a mighty rumble in this country, an outburst of anger and fear.''
What comes next may be the most pressing problem facing Republicans, who may find that dismantling the health law is far easier than replacing it with one that can unite their fractious members -- and win over some Democrats.
After a marathon session, the Senate voted 51 to 48 to approve a budget measure that would clear the way for the health care law to be repealed with a simple Senate majority. As the House approached its vote, some Republicans remained reluctant to act without a clear strategy to replace the health law.
''We'd like to see a little more flesh on the bone before we sign on the dotted line,'' said Representative Andy Harris of Maryland, an anesthesiologist and a member of the conservative House Freedom Caucus.
Republicans skeptical of moving forward risked looking hostile to the repeal effort. And there was a prevailing sense of the importance of following through on a campaign promise upon which so many House Republicans had staked their political reputations.
''This is an issue that really and truly, in some ways, put two-thirds of our conference here,'' said Representative Doug Collins of Georgia, a member of the party's leadership team.
''Everybody wants to get it right,'' he said.
Republican leaders sought to reassure members that the House budget vote -- procedurally important as it is -- is only the first step in an exhaustive process to repeal and replace the Affordable Care Act. Four committees in the House and Senate would then be tasked with drafting the legislation that would gut the existing health law.
The concerns fostered a remarkable alignment between some centrist Republicans and their counterparts in the House Freedom Caucus, the hard-right group that is disposed to disagree with its own party's leaders.
Speaker Paul D. Ryan of Wisconsin worked to soothe concerns even as he expressed the urgent need to get rid of a law that Republicans hate. Republicans would embark on ''a thoughtful, step-by-step process,'' he said, even though the law is ''collapsing while we speak.''
Mr. Ryan also said he was working with Mr. Trump and Vice President-elect Mike Pence. Mr. Trump called this week for a near simultaneous repeal and replacement of the Affordable Care Act.
''We are in complete sync,'' Mr. Ryan said.
But Republicans face a significant challenge in passing the necessary legislation to replace the health care law. They can repeal major parts of the existing law without facing a filibuster, but they would not be able put in place a full replacement in the same measure, because arcane budget rules limit what can be included in such a filibuster-proof bill.
Instead, they would almost certainly need to pass another bill or multiple bills with 60 Senate votes, and that would require at least some Democratic cooperation.
Senator Joe Manchin III, Democrat of West Virginia, a prime target for Republican wooing, asserted on Thursday that Mr. Trump did not want to ''repeal'' Obamacare but ''repair'' it. He cited Mr. Trump's stated support for popular provisions like requiring insurers to provide coverage for people with pre-existing medical conditions.
''We're in a repair mode,'' Mr. Manchin said. ''They need 60 votes to repair. I'm actually happy to work with them.''
Republicans in Congress have offered many replacement ideas, but it is not clear whether their most conservative members will ever be able to agree on legislation acceptable to the party's moderates.
A manifesto issued by House Republicans in June outlined a consensus proposal, produced by the chairmen of four House committees, including Representative Tom Price of Georgia, chosen by Mr. Trump to be secretary of health and human services.
Mr. Trump and congressional leaders said they were counting on Mr. Price to help them write a replacement for the Affordable Care Act, most likely drawing from a bill that he introduced in July 2009 and has reintroduced several times since.
''I think there's an acknowledgment both by the administration coming in and people around here that his imprint needs to be on this,'' Senator Bob Corker, Republican of Tennessee, said.
Senate Republicans do not have a detailed plan. But Senator Lamar Alexander of Tennessee, chairman of the health committee, laid out a road map on the Senate floor this week that pointed to a measure potentially more expansive than House plans.
The major Republican proposals have not been analyzed by the Congressional Budget Office, so no independent or authoritative estimates exist of their costs or the number of people who might gain or lose coverage.
On several points, the major Republican proposals agree.
They would eliminate the requirements that most Americans carry health insurance and that larger employers offer it to employees.
They would offer tax credits for health insurance and new tax incentives for health savings accounts; provide subsidies for state high-risk pools, to help people who could not otherwise obtain insurance; and make it easier for insurance companies to sell policies across state lines.
They would also provide some protection for people with pre-existing conditions who have maintained ''continuous coverage.'' They could not be dropped by an insurer and could move from one plan to another, but a person with a pre-existing condition seeking insurance after a lapse of coverage could in some cases be charged higher rates. The protections would be weaker than those in the Affordable Care Act.
Republicans also do not agree on how to pay for a replacement plan. In the House document, Republicans proposed limiting the value of tax-free health benefits that employers could provide to employees.
Under the current law, employees do not have to pay federal income tax on contributions that employers make to their health insurance. House Republicans said this open-ended subsidy had encouraged people to select more expensive coverage, driving up premiums.
But business groups, labor unions and some conservative lawmakers vehemently oppose that change, saying it amounts to a new tax on benefits and on working families. Senate Republicans have also not expressed support for the idea.
Many House Republicans, including Mr. Price, would provide tax credits to help people buy insurance. But the amount of assistance would increase with age and would not be tied to income, as it is under the existing health care law.
The subsidies would probably be smaller than under the Affordable Care Act. But insurance would be less expensive, Republicans say, because the government would impose fewer requirements.
Mr. Alexander said he would ''allow individuals to use their Obamacare subsidies to purchase state-approved insurance outside the Obamacare exchanges.'' Under the health care law, such assistance can be used only in the insurance exchanges.
Many Republicans say states should have much more power to define ''essential health benefits.''
On Medicaid, the federal insurance program for low-income people, House Republicans would roll back the Affordable Care Act's expansion and give each state a fixed amount of money for each beneficiary -- or a lump sum of federal money for all of a state's Medicaid program.
But more than half the states, including some with Republican governors, have expanded Medicaid eligibility under Mr. Obama's law, with large sums of federal money, and pragmatic Republicans are reluctant to snatch away the federal money that has allowed big increases in Medicaid enrollment.
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URL: http://www.nytimes.com/2017/01/12/us/politics/congress-affordable-care-act.html
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January 5, 2017 Thursday
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The Health Care Plan Voters Want
BYLINE: By DREW ALTMAN.
Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation.
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This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump -- people who are enrolled in the very health care marketplaces created by the law -- one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.
Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.
The Kaiser Foundation organized six focus groups in the Rust Belt areas -- three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn't really know what he would do, and were worried about what would come next.
They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance -- for which they were eligible for subsidies -- saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.
Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act -- including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage -- several of these Trump voters recoiled, calling such proposals ''not insurance at all.'' One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.
When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called ''chaos'' if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, ''a smart businessman like Trump would let that happen.'' Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.
There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as ''un-American.''
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.
Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.
In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.
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July 9, 2015 Thursday
Late Edition - Final
Insurers' Request for Higher Rates
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LENGTH: 515 words
To the Editor:
Re ''Insurers Seek Steep Increases in Plans' Rates'' (front page, July 4):
Surveys show that at least 15 percent of us oppose the Affordable Care Act from the left, because it doesn't go far enough in addressing the dysfunction of American health care financing. Your headline illustrates why.
Rather than addressing the root reasons that Americans pay over twice as much per capita in health care costs as most Europeans, the Affordable Care Act ceded any debate on the health care industry's ransom demands and simply looked for ways to pay it. Yes, there is funding for small pilot projects looking for cost savings, but in large part the insurers' sacrosanct profit margins and spending priorities were never allowed to be questioned.
Is it any wonder that insurers' stock prices shot up when the act was signed into law? Far from being the socialist nightmare portrayed by Republicans, the Affordable Care Act is the epitome of a free-market solution. Open competition was supposed to rein in prices and benefit consumers. But without competition from a truly nonprofit, government-funded option, the act simply feeds the insurance companies' insatiable appetite for profits.
SHEL KHIPPLE
Wilmette, Ill.
The writer is a doctor.
To the Editor:
The insurance companies, which fought Obamacare intensely until they realized the immense profits to be made, are now boohooing again. They say that they underestimated the cost of claims, are losing money and must increase premiums dramatically, from 20 to 40 percent or more.
The current monthly cost for unsubsidized coverage of an individual can be greater than $700. Many people already are struggling to afford that.
If the insurance companies are suffering financially, then why have their stock prices in the last year risen far more than that of the overall market? As of this writing, Aetna stock is up 51 percent, Cigna 73 percent, Anthem 48 percent for the year. And why is the total compensation for some insurance company chief executives greater than $10 million?
If our country had chosen a single-payer system or public option, I would happily contribute to the essential goal of providing health care for all. I am not so happy about providing excessive profits to the insurance companies and their overcompensated C.E.O.'s.
MELINDA HANSEN
San Diego
The writer is a nurse.
To the Editor:
Surely there can be no better argument for a national single-payer health care system than health insurance officials saying that new customers turned out to be sicker than they expected. Of course they are, because before the Affordable Care Act many of them had no insurance and no access to preventive medicine other than emergency rooms.
The rate increases noted in the article range from 23 to 54 percent. These outrageous demands will force people to whom the Affordable Care Act gave some hope back into misery from lack of medical attention because they cannot afford the costs. This will effectively begin to dismantle the program that is President Obama's legacy.
MICHAEL GOLDING
Fort Myers, Fla.
URL: http://www.nytimes.com/2015/07/09/opinion/health-insurers-request-for-higher-rates.html
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March 25, 2017 Saturday
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G.O.P. Revolt Sinks Bid to Void Health Law
BYLINE: By ROBERT PEAR, THOMAS KAPLAN and MAGGIE HABERMAN; Jennifer Steinhauer, Glenn Thrush and Emmarie Huetteman contributed reporting.
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WASHINGTON -- House Republican leaders, facing a revolt among conservatives and moderates in their ranks, pulled legislation to repeal the Affordable Care Act from consideration on the House floor Friday in a major defeat for President Trump on the first legislative showdown of his presidency.
''We're going to be living with Obamacare for the foreseeable future,'' the House speaker, Paul D. Ryan, conceded.
The failure of the Republicans' three-month blitz to repeal President Barack Obama's signature domestic achievement exposed deep divisions in the Republican Party that the election of a Republican president could not mask. It cast a long shadow over the ambitious agenda that Mr. Trump and Republican leaders had promised to enact once their party assumed power at both ends of Pennsylvania Avenue.
And it was the biggest defeat of Mr. Trump's young presidency, which has suffered many. His travel ban has been blocked by the courts. Allegations of questionable ties to the Russian government forced out his national security adviser, Michael T. Flynn. Tensions with key allies such as Germany, Britain and Australia are high, and Mr. Trump's approval ratings are at historic lows.
Republican leaders were willing to tolerate Mr. Trump's foibles with the promise that he would sign into law their conservative agenda. The collective defeat of the health care effort could strain that tolerance.
Mr. Trump, in a telephone interview moments after the bill was pulled, tried to put the most flattering light on it. ''The best thing that could happen is exactly what happened -- watch,'' he said.
''Obamacare unfortunately will explode,'' Mr. Trump said later. ''It's going to have a very bad year.'' At some point, he said, after another round of big premium increases, ''Democrats will come to us and say, 'Look, let's get together and get a great health care bill or plan that's really great for the people of our country.'''
Mr. Trump expressed weariness with the effort, though its failure took a fraction of the time that Democrats devoted to enacting the Affordable Care Act in 2009 and 2010. ''It's enough already,'' the president said.
A major reason for the bill's demise was the opposition of members of the conservative House Freedom Caucus, which wanted more aggressive steps to lower insurance costs and to dismantle federal regulation of insurance products.
In a day of high drama, Mr. Ryan rushed to the White House shortly after noon on Friday to tell Mr. Trump he did not have the votes for a repeal bill that had been promised for seven years -- since Mr. Obama signed the landmark health care law. During a 3 p.m. phone call, the two men decided to withdraw the bill rather than watch its defeat on the House floor.
Mr. Trump later told journalists in the Oval Office that Republicans were 10 to 15 votes short of what they needed to pass the repeal bill.
The effort to win passage had been relentless, and hardly hidden. Vice President Mike Pence and Tom Price, the health secretary, visited Capitol Hill on Friday for a late appeal to House conservatives, but their pleas fell on deaf ears.
''You can't pretend and say this is a win for us,'' said Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, who conceded it was a ''good moment'' for Democrats.
''Probably that champagne that wasn't popped back in November may be utilized this evening,'' Mr. Walker said.
At 3:30 p.m. on Friday, Mr. Ryan called Republicans into a closed-door meeting to deliver the news that the bill would be withdrawn, with no plans to try again. The meeting lasted five minutes. One of the architects of the House bill, Representative Greg Walden, Republican of Oregon and the chairman of the Energy and Commerce Committee, put it bluntly: ''This bill's done.''
''We are going to focus on other issues at this point,'' he said.
The Republican bill would have repealed tax penalties for people without health insurance, rolled back federal insurance standards, reduced subsidies for the purchase of private insurance and set new limits on spending for Medicaid, the federal-state program that covers more than 70 million low-income people. The bill would have repealed hundreds of billions of dollars in taxes imposed by the Affordable Care Act and would also have cut off federal funds to Planned Parenthood for one year.
Mr. Ryan had said the bill included ''huge conservative wins.'' But it never won over conservatives who wanted a more thorough eradication of the Affordable Care Act. Nor did it have the backing of more moderate Republicans who were anxiously aware of the Congressional Budget Office's assessment that the bill would leave 24 million more Americans without insurance in 2024, compared with the number who would be uninsured under the current law.
The budget office also warned that in the short run, the Republicans' legislation would drive insurance premiums higher. For older Americans approaching retirement, the cost of insurance could have risen sharply.
With the House's most hard-line conservatives holding fast against the bill, support for the legislation collapsed Friday after more and more Republicans came out in opposition. They included Representatives Rodney Frelinghuysen of New Jersey, the soft-spoken chairman of the House Appropriations Committee, and Barbara Comstock of Virginia, whose suburban Washington district went for the Democratic presidential nominee, Hillary Clinton, in November.
''Seven years after enactment of Obamacare, I wanted to support legislation that made positive changes to rescue health care in America,'' Mr. Frelinghuysen said. ''Unfortunately, the legislation before the House today is currently unacceptable as it would place significant new costs and barriers to care on my constituents in New Jersey.''
The bill died after Republican leaders, in a bid for conservative support, agreed to eliminate federal standards for the minimum benefits that must be provided by certain health insurance policies.
''It's so cartoonishly malicious that I can picture someone twirling their mustache as they drafted it in their secret Capitol lair last night,'' said Representative Jim McGovern, Democrat of Massachusetts. ''Republicans are killing the requirements that insurance plans cover essential health benefits'' such as emergency services, maternity care, mental health care, substance abuse treatment and prescription drugs.
Mr. Trump blamed Democrats for the bill's defeat, and they proudly accepted responsibility.
''Let's just, for a moment, breathe a sigh of relief for the American people that the Affordable Care Act was not repealed,'' said Representative Nancy Pelosi of California, the House Democratic leader.
Defeat of the bill could be a catalyst if it forces Republicans and Democrats to work together to improve the Affordable Care Act, which members of both parties say needs repair. Democrats have been saying for weeks that they want to work with Republicans on such changes, but first, they said, Republicans must abandon their drive to repeal the law.
''Obamacare is the law of the land,'' Mr. Ryan said. ''It's going to remain the law of the land until it's replaced.''
Whatever success Mr. Trump had in making business deals, he utterly failed in his first effort at cutting a deal at the pinnacle of power in Washington, Democrats said.
''This is not the art of the deal,'' said Representative Lloyd Doggett, Democrat of Texas, alluding to Mr. Trump's best-selling book. ''It is the art of the steal, of taking away insurance coverage from families that really need it to provide tax breaks for those at the very top.''
Rejection of the repeal bill may prompt Republicans to reconsider the political strategy they were planning to use for the next few years.
''We have to do some soul-searching internally to determine whether or not we are even capable of functioning as a governing body,'' said Representative Kevin Cramer, Republican of North Dakota. ''If 'no' is your goal, it's the easiest goal in the world to reach.''
Representative Robert Pittenger, Republican of North Carolina, offered this advice to hard-line conservatives who helped sink the bill: ''Follow the example of Ronald Reagan. He was a master; he built consensus. He would say, 'I'll take 80 percent and come back for the other 20 percent later.'''
Failure of the House effort leaves the Affordable Care Act in place, with all the features Republicans detest.
''We tried our hardest,'' said Representative Michael C. Burgess of Texas, chairman of the Energy and Commerce subcommittee on health. ''There were people who were not interested in solving the problem. They win today.''
''The Freedom Caucus wins,'' he added. ''They get Obamacare forever.''
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/03/24/us/politics/health-care-affordable-care-act.html
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GRAPHIC: PHOTOS: President Trump spoke Friday after the health bill was withdrawn and predicted the current health care program would not last. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
Speaker Paul D. Ryan was unable to muster enough votes. (A1)
''Let's just, for a moment, breathe a sigh of relief'' that the Affordable Care Act remains in place, Representative Nancy Pelosi, the Democrats' leader, said on Friday. (PHOTOGRAPHS BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES) (A14)
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September 4, 2014 Thursday
'Obamacare' Challengers Lose Again
BYLINE: JESSE WEGMAN
SECTION: OPINION
LENGTH: 383 words
HIGHLIGHT: The federal appeals court in D.C. tossed out a ruling that would have gutted the Affordable Care Act.
On Thursday morning, as almost everyone predicted it would, the federal appeals court in Washington, D.C., voted to toss out a three-judge panel's ruling upholding the latest attempt to kill "Obamacare." The full 11-member court is scheduled to rehear the case on Dec. 17.
The claim this time was that subsidies for the health exchanges that are at the heart of the law are available only to those exchanges "established by the State." In other words, not available in the three dozen states where the federal government has set up an exchange because the state refused to. This would result in the denial of coverage to an estimated 4.7 million Americans.To succeed, the claim required that those four words be considered in a hermetically sealed tube, independent from the rest of the 900-page law, whose core purpose was to ensure affordable health-care to lower-income Americans.
Luckily for the challengers, two of the three panel judges in the case, Halbig v. Burwell, were sympathetic to that way of reading the law. The third was less impressed, calling it a "not-so-veiled attempt to gut" the Affordable Care Act.
The rehearing will occur before a court with a majority of judges appointed by Democratic presidents. For that reason, many predict that the court will side with the government and reject the challengers' claim.
This matters because the challengers desperately wanted to pole-vault over the D.C. appeals court and go straight to the Supreme Court - where they believe they have their best shot at winning once and for all. It's the high-stakes version of what lawyers call "forum-shopping" - each side maneuvering to get a case into the court where they feel their chances are best.
While it's generally wise to avoid gaming out judges' votes based simply on the party of their appointing president, in the Halbig case, that has been a reliable proxy.
Of course, a key reason for the current makeup of the D.C. appeals court is the Senate's reform of the filibuster process last fall, which was triggered by Republicans' refusal to allow a vote on any of President Obama's three nominees to that court. After the reform, all three nominees were confirmed.
If anyone was wondering what the hue and cry over filibuster reform was really about in practice, the Halbig case is Exhibit A.
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February 27, 2013 Wednesday
In Massachusetts We Trust
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 837 words
HIGHLIGHT: Many people look to the Massachusetts health care law as a model of what the nation’s Affordable Care Act may bring, but the impact on labor markets reflects very different approaches, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
From a labor-market perspective, the Affordable Care Act has little in common with the 2006 health reform law implemented in Massachusetts.
Some employers are complaining about the $2,000 per-employee-per-year penalty they will pay beginning next year when the main provisions of the Affordable Care Act go into effect. The Congressional Budget Office also warned about the astonishing increase in marginal tax rates that middle-income Americans will experience, because the additional income earned by a family will be considered by the Internal Revenue Service as available for additional health insurance payments.
One might guess that large changes like these would shock the nation's labor markets, especially the markets for less-skilled workers for whom $2,000 is a significant sum, not to mention the costs of health insurance.
The United States Department of Health and Human Services rejects these concerns, saying that the experience in Massachusetts suggests "that the health care law will improve the affordability and accessibility of health care without significantly affecting the labor market," The Washington Examiner reported. The Urban Institute also thinks the Massachusetts results will accurately model the national market.
If there were another country or region that had already tried the federal Affordable Care Act, we would learn a lot from the results, regardless of how much business people might be complaining. However, even though the Affordable Care Act and the Massachusetts law are both forms of "health reform," and both seek to reduce the number of people without health insurance, they are quite different in terms of the labor-market incentives they create.
One of several unique features of the Massachusetts law is that it attempts to leverage the exclusion of employer-provided health insurance from federal personal income tax for the purpose of getting insurance to the previously uninsured. The law encouraged employers to set up a "125 plan" that allows employees to use their own pretax dollars to buy health insurance.
Under a 125 plan, an employer need not pay for employee health insurance: the employer only assists a bit in the administration of the premium payments and withholding. The premium payments themselves come from employee paychecks. And the 125 plans are for employees (who may buy insurance on behalf of their families), not for people without jobs.
Even before the law was passed, Massachusetts employers typically offered some kind of health insurance plan to employees. The state law pushed a significant fraction of the remaining few to try the 125 approach by threatening to bill noncompliant employers for the uncompensated care their employees received around the state, a penalty known as the "free-rider surcharge." So far, studies have found that enough employers took on 125 plans that ultimately no employers were liable for the surcharge.
In contrast, the federal Affordable Care Act attempts to nudge the national labor market away from the federal tax exclusion for employer-provided insurance by offering large subsidies only to people who are not part of an employer plan, including people who are not employed. The act also passes judgment on the affordability of employer plans and penalizes employers who offer "unaffordable" plans and then have employees who receive the subsidies. The federal penalties can reach $3,000 per employee and are not deductible from business taxes.
As long as they do something like the 125 plan to help their employees use the federal tax exclusion, Massachusetts employers are only nominally responsible for the "affordability" of health insurance or for failures of their employees to take advantage of the plan offered. The Massachusetts penalty is only $295 per employee-year (as far as I can tell, it is business tax-deductible, which makes the $295 less than one-tenth of the federal penalty); it can be avoided by an employer that makes nominal contributions to its employees' premiums and induces enough employees to participate.
Perhaps it's wise for the Affordable Care Act to push in a different direction than Massachusetts did, because many economists think the federal personal income tax exclusion promotes health care inefficiencies and diverts much-needed revenue from the United States Treasury.
But that wisdom doesn't change the fact that the federal law will put very different pressures on employers and employees than the Massachusetts law does. It would be unwise to assume that next year's national labor market will follow the patterns that the labor market in Massachusetts experienced after 2006.
Health Care Aside, Fewer Jobs Than in 2000
Older Workers Could Benefit if Companies Drop Insurance
The Incomes of Physicians
Measuring the 'Quality' of Health Care
Reader Response: Medicare Options and Quality of Care
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August 14, 2013 Wednesday
Mitch McConnell Tries Leadership, Then Backs Away
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 251 words
HIGHLIGHT: He knows a government shutdown won’t stop the Affordable Care Act. But he won’t outright oppose the plan.
Yesterday Mitch McConnell, the Senate minority leader, appeared to attempt to act like a leader by throwing cold water on the government shutdown plan, which many Republicans have endorsed as a way to stop the implementation of the Affordable Care Act.
"The problem is the bill that would shut down the government wouldn't shut down Obamacare," Mr. McConnell told a group of healthcare workers in southern Kentucky. "Most of it is permanent law and not affected by that. It also wouldn't stop the taxes. Taxes that are going in on medical devices, taxes that are going in on health insurance premiums."
According to WYMT, Mr. McConnell even copped to sort of liking certain aspects of the president's health reform law.
"There are a handful of things in the 2,700-page bill that probably are okay," Mr. McConnell said.
Will wonders never cease? Yes, in fact, they will.
After sounding sensible for a second, Mr. McConnell told The Washington Post's Greg Sargent that he did not mean to "take sides in the dispute over whether to stage a shutdown confrontation. He was merely stating a fact - that even if the government is shut down, it won't stop the funding of Obamacare."
To recap: Mr. McConnell knows the shutdown won't work as intended, but he's not willing to actually come down against it.
McConnell's Campaign Manager 'Holding His Nose'
Cheerleader for Healthcare Repeal Retires, Blaming Gridlock
The 'Just Say No' Approach to Governing
Mitch McConnell Tries to Save Face
The Koch Brothers' Advertising Campaign
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February 14, 2014 Friday
Tax Subsidies and the Incentive to Work
SECTION: BUSINESS; economy
LENGTH: 1305 words
HIGHLIGHT: Debate over the effect of the Affordable Care Act on the labor market underscores an inherent trade-off in means-tested public assistance, and gauging the impact is an imprecise art, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
Last week a brouhaha erupted over a passage in Appendix C of a Congressional Budget Office report, Budget and Economic Outlook 2014-24.
In that appendix, "Labor Market Effects of the Affordable Care Act: Updated Estimates," the agency reported its estimate that the Affordable Care Act "will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor - given the new taxes and other incentives they will face and the financial benefits some will receive."
The agency estimated this reduction in hours worked as the "full-time-equivalent workers of about 2 million in 2017, rising to about 2.5 million in 2024." The agency hastens to point out that this number does not represent jobs no longer offered by employers but, for the most part, the decision of employees not to work.
Opponents of the Affordable Care Act and many news reports quickly seized upon this estimate, characterizing it as "dropping a bomb" or having "nuked" Obamacare. Joseph Rago of The Wall Street Journal attributed this interpretation of the data to an exposé by my fellow Economix blogger Casey B. Mulligan.
Commentators supporting the Affordable Care Act pointed out that the pro-growth effect of the law's lower health costs would swamp any antigrowth effects from a lower labor supply and that if some Americans decided to work less, given the incentives they face, they would yield available jobs to others willing to work but unable to find a job, which on balance would be a good thing.
It is worth reading Appendix C of the C.B.O. report to get a feel for what is really at stake here. In that appendix the agency explains, for example, that its "estimate that the A.C.A. will reduce employment reflects some of the inherent trade-offs involved in designing such legislation." Further clarification was offered in a "Frequently Asked Questions" statement by the C.B.O.
The agency alludes there to the fact that any program offering means-tested public assistance to citizens will do much good but implicitly confront citizens with higher marginal tax rates that may induce these beneficiaries to work fewer hours or even retire. As Professor Mulligan properly notes, it is not the economist's job to come to a judgment on this trade-off.
The clearest and easiest vehicle for explaining this trade-off is the negative income tax. It was most famously proposed in this country by Milton Friedman, the late conservative economist and Nobel laureate, in his classic "Capitalism and Freedom" (1962). What ultimately happened to this idea is well told in a history of the concept by Jody T. Allen. It need not detain us here.
Friedman explained his rationale for and the modus operandi of his idea clearly in a 1968 video clip, during a conversation with the late William F. Buckley Jr.
In this scheme a, say, family of four with an earned income (call it Y) below a certain threshold income level (call it X) receives public financial assistance calculated as flat "tax rate" of "t" on the amount (Y - X). In other words, the tax - actually a negative tax or a subsidy - is
TAX = t(Y - X), when Y is less than X.
Because the TAX in this expression is negative when, as we assume, Y is less than X, economists would say that the family "pays" a negative income tax. In plainer in English it means it is receiving a public subsidy.
In the video clip, by the way, Friedman assumes a flat marginal income tax rate of t = 50 percent, a rate even higher than the marginal tax calculated by Professor Mulligan for the Affordable Care Act.
The graph below depicts Friedman's idea, although I use different numbers, because the Consumer Price Index has increased by a factor of about 6.5 since 1968. In that graph, I assume that the minimum guaranteed income (the maximum cash assistance) for the family in question is M = $20,000 if it has no earned income or any other income at all, and I assume two different tax rates: t = 25 percent and t = 50 percent.
The red line in the graph assumes a tax rate of t = 50 percent and shows how quickly federal cash assistance melts away as the family's earned income rises, which means that the family faces a strong disincentive for work to earn income. The threshold income below which a subsidy is received here is X = M/t = $20,000/0.5 = $40,000 only.
The blue line assumes a tax rate of only t = 25 percent, driving the threshold income to X = 20,000/0.25 = $80,000. That scheme confronts the family with less of an incentive not to work and earn income; but the price for that is a much higher federal assistance budget.
The sizes of the total federal assistance budget implied by these two alternative tax rates cannot be read off the graph, because households are not evenly distributed along the income range on the horizontal axis; more households will be in one income range than another. But whatever the distribution of households along the income scale may be, it is clear that, for a given minimum guaranteed income (M), the size of the federal assistance budget rises when the tax rate decreases. At the 50 percent tax rate, for example, no household with an income above $40,000 and below $80,000 gets any assistance. At the 25 percent rate they do.
In designing such a scheme, lawmakers thus must trade off among (a) the generosity toward the poorest members of society (M), (b) the disincentive to work baked into the scheme and (c) the total federal budget for cash assistance in the form of negative taxes. Whatever is put in place will naturally be a compromise.
Although a negative income tax scheme is the clearest way to illustrate the trade-off to which the Congressional Budget Office alluded, that trade-off is inherent in any means-tested federal assistance program intended for the poor.
Details on the nature of that means-testing built into the Affordable Care Act, for example, can be found on the Kaiser Family Foundation's convenient website. If readers wish to get a feel for how quickly the amount of federal assistance under the program melts away with higher earned income in their own situation, I recommend playing around with the foundation's handy premium-subsidy calculator.
Finally, to return to the estimated reduction in work effort reported in Appendix C of the Congressional Budget Office report, the following should be kept in mind: it is merely an estimate.
Calculating the marginal tax rate inherent in the Affordable Care Act, which can be done with reasonable accuracy, is only half the story.
The rest depends on what assumption one makes concerning the likely behavioral response of employed or unemployed workers to changes in marginal income-tax rates.
There is not just one response coefficient that every economist would use. Usually the literature offers a fairly wide range of previously estimated response coefficients. For that reason, different economists can easily come up with different estimates of reduced worker hours.
Taking into account both estimated changes in demand and supply, Professor Mulligan, for example, projects a reduction in the total number of hours worked under the Affordable Care Act as equivalent to 3 percent relative to the number of hours likely to have been worked in the absence of the law. The C.B.O. has that number at 1.5 to 2 percent over the coming decade. Other economists might arrive at an even lower estimate.
That, alas, is the nature of economic analysis.
Demoralization Is Not a Policy Achievement
A Report's Real Message: It Wasn't About Health Care
The Economics of Being Kinder and Gentler in Health Care
The Dubious Case for Professional Licensing
The New Subsidy for Layoffs
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October 2, 2013 Wednesday
The Tax Equation in the Health Care Law
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 798 words
HIGHLIGHT: In the marketplaces created by the Affordable Care Act are benefits for lower-wage workers, but also potential disincentives to work full time, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
In more ways than one, the new health insurance "marketplaces" are a big deal for low-wage workers.
Beginning this week, families can use the Affordable Care Act's marketplaces to enroll for health insurance coverage that begins Jan. 1, and in many cases receive federal assistance with their premiums and other health costs on the basis of their expected income for calendar year 2014.
Because people who work part time or are unemployed for part of the year have less annual income than people who work full time and all year, working less means qualifying for more generous subsidies. By working part time or not at all, participants in the marketplaces will also create fewer penalties for employers who don't make affordable coverage available once those penalties go into effect in 2015. (Employers are penalized only for full-time employees and only during the months that they are on the payroll.)
These new rules will make it less rewarding to be a full-time worker and a little less burdensome to be unemployed or underemployed. In my testimony in June before the Subcommittee on Human Resources of the House Ways and Means Committee, I quantified these new disincentives in terms of marginal tax rates - the percentage of compensation lost from paying taxes and replacing benefits associated with not working. The group I looked at was non-elderly household heads and spouses whose earnings abilities - that is, the amount that they earn when they are working full time - are in the middle of the distribution, earning roughly $800 per week when the work is full time.
Such workers (hereafter "midwage workers") will see their marginal tax rates increase by an average of five percentage points between now and 2016, taking into account that many people will not take part in programs for which they are eligible for help. Before the Affordable Care Act, the compensation for each additional hour of work by a midwage worker was, on average, split 55 percent for the employee and 45 percent for the government (the government got its part by receiving more taxes from the employee, and paying fewer benefits, such as unemployment insurance payouts and food stamps, to the employee). Under the act, the split will be 50-50.
The unemployment rate, the employment rate and the propensity to work full time are usually measured nationwide, with every adult counting in the average regardless of whether he or she is a low-wage worker, a high-wage worker or somewhere in between. It's worth giving attention to midwage workers because, by definition, much of the population is fairly close to the middle.
But is also informative to look at low-wage workers, because they are more likely to fall into poverty and their employment patterns may be more sensitive to incentives.
It turns out that low-wage workers will also see a reduction in their reward to work over the next couple of years, and to a greater degree than workers in the middle will. The chart below compares the five-percentage-point result for midwage workers and its components, with the tax-rate changes for low-wage workers (by which I mean workers who earn roughly $550 per week when they work full time, which is roughly twice minimum wage).
Work incentives for low-wage workers are eroded more than 10 percent of their compensation over the next couple of years, compared with 5 percent for midwage workers. Before the Affordable Care Act, the compensation for each additional hour of work by a low-wage worker, as with midwage workers, was split 50 percent, on average, for employee and 50 percent for the government. Under the law, it will be 39-61.
One reason that low-wage workers will have a greater shift in their incentives is that, because they earn less, a given dollar amount is a greater percentage of their compensation than it would be for a midwage worker.
More important, low-wage workers will qualify for larger dollar subsidies in the marketplaces than midwage workers will. Working full time or spending fewer weeks unemployed will mean less, or even zero, assistance with health expenses.
In other words, some good news from the new marketplaces is that low-wage workers will be given a lot of assistance with their health expenses. But that assistance has the unfortunate consequence of higher income taxes on low-wage people: working more rather than less will not pay as well under the Affordable Care Act than it does now.
Testing a Premise on the Health Care Law and Part-Time Work
The New Economics of Part-Time Employment
What Job-Sharing Brings
Looking for Furloughs in the Jobs Data
Full Time, Part Time, Good Jobs, Bad
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October 2, 2013 Wednesday
The Tax Equation in the Health Care Law
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 798 words
HIGHLIGHT: In the marketplaces created by the Affordable Care Act are benefits for lower-wage workers, but also potential disincentives to work full time, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
In more ways than one, the new health insurance "marketplaces" are a big deal for low-wage workers.
Beginning this week, families can use the Affordable Care Act's marketplaces to enroll for health insurance coverage that begins Jan. 1, and in many cases receive federal assistance with their premiums and other health costs on the basis of their expected income for calendar year 2014.
Because people who work part time or are unemployed for part of the year have less annual income than people who work full time and all year, working less means qualifying for more generous subsidies. By working part time or not at all, participants in the marketplaces will also create fewer penalties for employers who don't make affordable coverage available once those penalties go into effect in 2015. (Employers are penalized only for full-time employees and only during the months that they are on the payroll.)
These new rules will make it less rewarding to be a full-time worker and a little less burdensome to be unemployed or underemployed. In my testimony in June before the Subcommittee on Human Resources of the House Ways and Means Committee, I quantified these new disincentives in terms of marginal tax rates - the percentage of compensation lost from paying taxes and replacing benefits associated with not working. The group I looked at was non-elderly household heads and spouses whose earnings abilities - that is, the amount that they earn when they are working full time - are in the middle of the distribution, earning roughly $800 per week when the work is full time.
Such workers (hereafter "midwage workers") will see their marginal tax rates increase by an average of five percentage points between now and 2016, taking into account that many people will not take part in programs for which they are eligible for help. Before the Affordable Care Act, the compensation for each additional hour of work by a midwage worker was, on average, split 55 percent for the employee and 45 percent for the government (the government got its part by receiving more taxes from the employee, and paying fewer benefits, such as unemployment insurance payouts and food stamps, to the employee). Under the act, the split will be 50-50.
The unemployment rate, the employment rate and the propensity to work full time are usually measured nationwide, with every adult counting in the average regardless of whether he or she is a low-wage worker, a high-wage worker or somewhere in between. It's worth giving attention to midwage workers because, by definition, much of the population is fairly close to the middle.
But is also informative to look at low-wage workers, because they are more likely to fall into poverty and their employment patterns may be more sensitive to incentives.
It turns out that low-wage workers will also see a reduction in their reward to work over the next couple of years, and to a greater degree than workers in the middle will. The chart below compares the five-percentage-point result for midwage workers and its components, with the tax-rate changes for low-wage workers (by which I mean workers who earn roughly $550 per week when they work full time, which is roughly twice minimum wage).
Work incentives for low-wage workers are eroded more than 10 percent of their compensation over the next couple of years, compared with 5 percent for midwage workers. Before the Affordable Care Act, the compensation for each additional hour of work by a low-wage worker, as with midwage workers, was split 50 percent, on average, for employee and 50 percent for the government. Under the law, it will be 39-61.
One reason that low-wage workers will have a greater shift in their incentives is that, because they earn less, a given dollar amount is a greater percentage of their compensation than it would be for a midwage worker.
More important, low-wage workers will qualify for larger dollar subsidies in the marketplaces than midwage workers will. Working full time or spending fewer weeks unemployed will mean less, or even zero, assistance with health expenses.
In other words, some good news from the new marketplaces is that low-wage workers will be given a lot of assistance with their health expenses. But that assistance has the unfortunate consequence of higher income taxes on low-wage people: working more rather than less will not pay as well under the Affordable Care Act than it does now.
Testing a Premise on the Health Care Law and Part-Time Work
The New Economics of Part-Time Employment
What Job-Sharing Brings
Looking for Furloughs in the Jobs Data
Full Time, Part Time, Good Jobs, Bad
LOAD-DATE: October 2, 2013
LANGUAGE: ENGLISH
DOCUMENT-TYPE: News
PUBLICATION-TYPE: Web Blog
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(Economix)
October 2, 2013 Wednesday
The Tax Equation in the Health Care Law
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 798 words
HIGHLIGHT: In the marketplaces created by the Affordable Care Act are benefits for lower-wage workers, but also potential disincentives to work full time, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
In more ways than one, the new health insurance "marketplaces" are a big deal for low-wage workers.
Beginning this week, families can use the Affordable Care Act's marketplaces to enroll for health insurance coverage that begins Jan. 1, and in many cases receive federal assistance with their premiums and other health costs on the basis of their expected income for calendar year 2014.
Because people who work part time or are unemployed for part of the year have less annual income than people who work full time and all year, working less means qualifying for more generous subsidies. By working part time or not at all, participants in the marketplaces will also create fewer penalties for employers who don't make affordable coverage available once those penalties go into effect in 2015. (Employers are penalized only for full-time employees and only during the months that they are on the payroll.)
These new rules will make it less rewarding to be a full-time worker and a little less burdensome to be unemployed or underemployed. In my testimony in June before the Subcommittee on Human Resources of the House Ways and Means Committee, I quantified these new disincentives in terms of marginal tax rates - the percentage of compensation lost from paying taxes and replacing benefits associated with not working. The group I looked at was non-elderly household heads and spouses whose earnings abilities - that is, the amount that they earn when they are working full time - are in the middle of the distribution, earning roughly $800 per week when the work is full time.
Such workers (hereafter "midwage workers") will see their marginal tax rates increase by an average of five percentage points between now and 2016, taking into account that many people will not take part in programs for which they are eligible for help. Before the Affordable Care Act, the compensation for each additional hour of work by a midwage worker was, on average, split 55 percent for the employee and 45 percent for the government (the government got its part by receiving more taxes from the employee, and paying fewer benefits, such as unemployment insurance payouts and food stamps, to the employee). Under the act, the split will be 50-50.
The unemployment rate, the employment rate and the propensity to work full time are usually measured nationwide, with every adult counting in the average regardless of whether he or she is a low-wage worker, a high-wage worker or somewhere in between. It's worth giving attention to midwage workers because, by definition, much of the population is fairly close to the middle.
But is also informative to look at low-wage workers, because they are more likely to fall into poverty and their employment patterns may be more sensitive to incentives.
It turns out that low-wage workers will also see a reduction in their reward to work over the next couple of years, and to a greater degree than workers in the middle will. The chart below compares the five-percentage-point result for midwage workers and its components, with the tax-rate changes for low-wage workers (by which I mean workers who earn roughly $550 per week when they work full time, which is roughly twice minimum wage).
Work incentives for low-wage workers are eroded more than 10 percent of their compensation over the next couple of years, compared with 5 percent for midwage workers. Before the Affordable Care Act, the compensation for each additional hour of work by a low-wage worker, as with midwage workers, was split 50 percent, on average, for employee and 50 percent for the government. Under the law, it will be 39-61.
One reason that low-wage workers will have a greater shift in their incentives is that, because they earn less, a given dollar amount is a greater percentage of their compensation than it would be for a midwage worker.
More important, low-wage workers will qualify for larger dollar subsidies in the marketplaces than midwage workers will. Working full time or spending fewer weeks unemployed will mean less, or even zero, assistance with health expenses.
In other words, some good news from the new marketplaces is that low-wage workers will be given a lot of assistance with their health expenses. But that assistance has the unfortunate consequence of higher income taxes on low-wage people: working more rather than less will not pay as well under the Affordable Care Act than it does now.
Testing a Premise on the Health Care Law and Part-Time Work
The New Economics of Part-Time Employment
What Job-Sharing Brings
Looking for Furloughs in the Jobs Data
Full Time, Part Time, Good Jobs, Bad
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May 8, 2012 Tuesday
Business Owners Try to Make Sense of Health Care
BYLINE: ADRIANA GARDELLA
SECTION: BUSINESS; smallbusiness
LENGTH: 1131 words
HIGHLIGHT: "Every single broker gives you different information," said one owner.
As if managing health care insurance isn't complicated enough already, the Supreme Court is expected to rule soon on the constitutionality of the partially implemented Affordable Care Act. During the most recent meeting of our business group, we asked the owners to talk about how they are handling this increasingly complicated, costly and uncertain issue.
Jessica Johnson, who owns Johnson Security Bureau, said that her employees fall into several categories. She has one client that requires her to offer health insurance to the security guards on its job, and the client helps Johnson Security by paying the guards a higher rate to cover the insurance if they want it - some don't.
Johnson Security also has some prevailing wage contracts that require it to pay a certain health and welfare benefit for every hour worked. The company provides this benefit in the form of a Health Reimbursement Arrangement card. Employees receive a health and welfare rate of $4.56 for every hour worked, Ms. Johnson said.
"They go out and get insurance themselves, you're just giving them money toward it?" asked Susan Parker, who owns Bari Jay.
"The money is in an account. They have debit cards, and when they go to the doctor or to the pharmacy, they can swipe the card," Ms. Johnson said.
"Like flex spending," Ms. Parker added.
Ms. Johnson said some of her employees have no form of health insurance, and a large percentage are on Medicaid or take advantage of a state program that provides health insurance to children in families with qualifying incomes. To the amazement of the group, Ms. Johnson said she falls into in the first category. She said she had been on COBRA after leaving her last pharmaceutical sales job but "months ago stopped counting" how long she has gone without insurance.
"We all want to slap you," Ms. Parker said.
"You and my mother," Ms. Johnson said.
The group members agreed that Ms. Johnson get health insurance. She responded, "As a business owner, you have to make choices about how you run your business and spend your money. Sometimes things don't make sense, but you do what you have to do."
Alexandra Mayzler, who owns Thinking Caps Tutoring, has health insurance and is trying to determine whether she can offer it to her employees in a sensible way. Until recently, Thinking Caps employed only students who worked part time as tutors, so the issue was less relevant.
Talking with insurance brokers leaves Ms. Mayzler confused about her options. "Every single broker gives you different information," she said. Just when she thinks she knows what to do, she learns of another complexity. For example, any plan she chose would probably be based on her number of employees and on the percentage that opt for insurance. Because her employee numbers are shifting, she said, she finds herself in a "chicken-egg" situation: "Do I figure out the insurance, or do I wait until I know who's staying?"
Ms. Parker offers her employees insurance - along with flexible spending accounts, a 401(k) plan, and profit sharing. "I let my mom deal with my insurance," she said. Ms. Parker's mother, a former nurse, is Bari Jay's director of human resources.
"I found a really good plan for New York, but I think our new administrative person is going to be from New Jersey," said Ms. Mayzler.
Several Bari Jay employees live in New Jersey. Ms. Parker said having workers in different states makes the process even more complicated.
"So complicated," agreed Ms. Mayzler, who has two employees in Texas.
When Ms. Johnson began investigating health insurance for her employees last year, she wondered whether the options would be the same for employees regardless of their state of residence. She said she learned that insuring her employees who reside in New York would cost more than insuring those who live in New Jersey.
"And you can't say I'm only going to cover New Jersey people and not New York," Ms. Mayzler said.
Defining full- and part-time workers is another issue for Ms. Johnson. While she might consider any employee who works 32 hours a week full time, the insurance company might use a lower number of hours to get the largest pool of people possible into the plan.
"Then they want to know how many people have other coverage," she said. "I may not know that - it may not be any of my business if somebody has coverage through their wife, significant other or whomever."
Complicating matters further, Johnson Security has gone from 40 to 80 employees in the last year. For insurance companies, "anything over 50 is considered a large employer," Ms. Johnson said. "I don't have large group employer dollars." But at 80 employees, she no longer qualifies for certain small-business programs.
She said that New York State offers a health insurance exchangelike program for businesses like hers. But after she repeatedly completed the program's online wizard, answering questions about, for example, her number of employees and their average income, Ms. Johnson was told that her company did not qualify. She would love to know why -- but the wizard offered no explanation. "I deal with the 1 percent of the 99 percent at the bottom of the barrel," she said. "And you're telling me these people don't qualify?"
Ms. Parker said that, before her mother took over, she used a payroll service to help her figure things out. "They were horrible, but at least that got me started," she said, adding that she had no patience for researching insurance options. "I'd just go with the cheapest plan my broker offered, throw in a few other plans, and call it a day," she said.
Her mother, on the other hand, is always willing to dig for a better deal. "She keeps going and going and going," Ms. Parker said. "She eventually gets it."
Her research is required every time Bari Jay's insurance is up for renewal and the company is confronted with a steep rise in insurance premiums. Thanks to Ms. Parker's mother, the company always seems to find a cheaper plan and give employees the choice of switching or paying a little more to keep their current plan. Almost everyone, Ms. Parker said, opts for the cheapest plan. "It will be interesting to see what happens when our renewal comes up in July," she said.
For her own insurance, Ms. Parker said she would choose the more expensive plan to avoid being limited to a small network of doctors. But like many of Bari Jay's employees, she is not on one of the company's plans. Instead, she is insured through a plan offered by her husband's employer, Morgan Stanley.
"Who's going to have better insurance," she asked, "Bari Jay or Morgan Stanley?"
Beyond Annual Performance Reviews
Behind an Owner's Complicated Union Ties
The Verdict on Business Huddles
Questioned by a Coach, an Owner Rethinks Her Manufacturing Issues
Bringing Employees Into the Conversation
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April 14, 2017 Friday
Late Edition - Final
Explaining the Health Payments That Trump Is Threatening to End
BYLINE: By REED ABELSON and MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 11
LENGTH: 871 words
Cost-sharing reductions seem like an arcane aspect of the Affordable Care Act, but they could now make or break the Obamacare insurance marketplaces. Even President Trump is talking about them, as a possible bargaining chip for a new health bill.
Mr. Trump this week repeatedly threatened to cut off the federal funding that makes the cost-sharing reductions work for insurers and patients. The idea, he told The Wall Street Journal, is that Democrats would be forced to negotiate with him over a replacement for the Affordable Care Act if they did not want the individual insurance market to collapse. The administration has been anything but clear about whether it wants that market to thrive or fail.
What exactly are the cost-sharing reductions?
The Affordable Care Act helps make health insurance affordable for low-income people in two ways. The government provides a subsidy to help buy a policy, but about seven million people also get help with their out-of-pocket costs when they go to the doctor or fill a prescription. The government pays the insurance companies extra -- $7 billion last year -- to offer plans with discounts on the usual deductibles and co-payments that might make medical care unaffordable for relatively poor consumers.
Why are they at risk?
There is no language in the bill explicitly linking the subsidies to a permanent funding source, but the Obama administration argued that Congress intended for the money to be paid alongside other subsidies, and the subsidies have been paid over the last three years.
House Republicans said what the Obama administration was doing was unconstitutional, and they brought a lawsuit to stop the payments. The House won, but the decision has not taken effect while the case is being appealed. The next court date is May 22. Now the Trump administration is in the awkward position of deciding whether to keep fighting the Obama administration's fight.
If Trump decides to stop paying them, what will happen?
Killing the cost-sharing subsidies would be a huge and immediate hit to insurance companies offering Obamacare plans. The companies are still required by law to offer their customers discounts, but they could lose the money to help fund them. Without the government payment, they would need to find another way to make up the difference.
Insurers could raise the price of insurance for everyone, a change that would affect even people who don't get the subsidies. The Kaiser Family Foundation has estimated premiums for a plan would go up by an average of 19 percent without the funding. (This paradoxically could end up costing the government a lot of money, since it is still required by law to help many customers pay their premiums.)
A decision to do away with the subsidies would also send a key signal to the insurance companies that the Trump administration and Congress have decided not to stabilize the market, which has been particularly shaky in some areas. Without the subsidies, insurance could get very expensive in some places in the country. In other areas, no insurance options might be available.
If Trump wanted to fix them, what could he do?
It's complicated.
The easiest way would be to encourage Republicans in Congress to pass an appropriations bill that explicitly funds the subsidies. They will have an opportunity soon: Congress is expected to vote on a short-term appropriations bill in the next few weeks.
The Trump administration could also keep fighting the House lawsuit in court. Many legal experts think that the administration has a good chance of winning if the case continues, since courts rarely recognize the right of Congress to sue the White House. It's not clear if the parties could settle the case in a way that preserves the subsidies, even if they wanted to.
Who wants the funding to continue?
A broad coalition of insurance companies, hospitals, doctors and patient groups want the subsidies to be paid. Democrats in Congress are also strong supporters of the cost-sharing reductions. A letter to the White House this week urging a resolution of the issue was signed by insurers, hospitals, doctors and even the solidly Republican Chamber of Commerce.
Who wants the funding to end?
The House leadership that brought the suit argued that the payments were worrisome because they represented illegal spending. But that does not mean that all Republicans in Congress want to see Obamacare markets in their home state fail. In fact, several key Republicans in Congress, including Greg Walden of Oregon, the chairman of the House Energy and Commerce Committee, have said that they would prefer Congress to pass legislation explicitly funding the subsidies.
But some people in the Trump White House believe that preserving the risk of market failures could create political pressure for a deal on a larger Obamacare replacement bill. On Wednesday, President Trump told The Journal, ''I don't want people to get hurt,'' then added, ''What I think should happen -- and will happen -- is the Democrats will start calling me and negotiating.''
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: https://www.nytimes.com/2017/04/14/upshot/explaining-the-health-payments-that-trump-is-threatening-to-end.html
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October 13, 2015 Tuesday
Jeb Bush to Detail Plans for Replacing the Affordable Care Act
BYLINE: MATT FLEGENHEIMER
SECTION: US; politics
LENGTH: 227 words
HIGHLIGHT: Jeb Bush will outline his proposal to replace President Obama’s health care law, calling for greater state authority over health policies and for a tax credit for the purchase of “affordable, portable health plans” for catastrophic medical events.
Jeb Bush will outline his proposal on Tuesday to replace President Obama's health care law, calling for greater state authority over health policies and for a tax credit for the purchase of "affordable, portable health plans" for catastrophic medical events.
According to the campaign, Mr. Bush, who will detail his plan during a speech in New Hampshire, would revamp the Food and Drug Administration's "regulatory morass" and increase funding for the National Institutes of Health.
He is also proposing an increase in contribution limits and uses for health savings accounts to address out-of-pocket costs and a cap on the tax exclusion of employer plans.
In a statement, a spokeswoman for Mr. Bush, Allie Brandenburger, said Mr. Obama's law "epitomizes why Americans are fed up with Washington," calling it "a government takeover of more than one-sixth of the American economy."
Mr. Bush, who has aimed to position himself as the most policy-oriented candidate in the Republican field, did not detail precisely how he would go about repealing the law, the Affordable Care Act. During a campaign stop in Iowa last week, he suggested that it would prove so unpopular that it would "collapse under its own weight."
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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(You're the Boss)
August 12, 2013 Monday
It's the Affordable Care Act. But What Is Affordable?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 928 words
HIGHLIGHT: The A.C.A. will require employers with more than 50 employees to estimate their employees’ household incomes. How are they supposed to do that?
Under the Affordable Care Act, if a company with 50 employees hopes to avoid the penalty in the so-called employer mandate, it is not enough to merely offer those workers health insurance. The insurance must be "affordable," among other things, and the law is very specific about what affordable means: It means the employee's share of the premium cannot exceed 9.5 percent of the employee's household income.
If this seems straightforward, putting it into action has been anything but. Household income is the benchmark because the Affordable Care Act ties affordability to the tax credits and subsidies available to help individuals purchase insurance in the new marketplaces created by the law. In fact, the penalty for employers who offer unaffordable insurance comes into play only when employees use these subsidies to buy their own insurance rather than accept the company's coverage.
But employers, of course, are in no position to know what their employees' household income might be, least of all as determined by the esoteric definition of household income used by the Internal Revenue Service. Among other things, determining household income would force employers to find out how much their employees' spouses make and even to track down certain private household expenses, like alimony payments.
So the I.R.S., which is writing the regulations for the mandate, has proposed three alternatives to determining household income, safe harbors that would permit employers to comply with the mandate and avoid the penalty. First, a company could use the wages it reports to the I.R.S. on Form W-2 as a substitute for household income. So long as the employee's share of the insurance premiums is no more than 9.5 percent of the wages reported in Box 1 of the form (meaning the amount excludes deferrals such as 401k or flexible spending account contributions), the coverage would be deemed affordable. (Again, this is for companies with more than 50 employees; smaller companies are under no obligation to provide health insurance.)
Or the company could calculate a baseline monthly wage based on the first month's hourly rate or salary. Unlike the W-2 option, the wage calculated here would not exclude deferrals, so it would likely be higher. However, if the company reduced the employee's hourly rate or salary over the year, it would not be able to use this option. And that eliminates this option for many companies, because they generally cannot plan for wage cuts, said Seth Perretta, an attorney from the Washington firm Crowell & Moring, who is representing several trade groups in the rule making.
Finally, the company could simply substitute the federal poverty level guidelines for an individual for the employee's actual household income. In 2013, the federal poverty level for an individual in the mainland United States is $11,490. "The practical effect there is that if you have coverage that is affordable at that level, it's definitely going to be affordable by the time the I.R.S. comes looking" at an employee's household income, Mr. Perretta said.
With each of the safe harbors the I.R.S. has proposed, employers trade convenience or certainty for, potentially, a lower threshold for affordability. For example, imagine a household where the husband and wife earn $50,000 apiece: If the husband's employer uses the W-2 safe harbor, the company's affordability threshold falls from 9.5 percent of household income to 4.75 percent, which means the employer will have to pick up a larger portion of the employee's insurance premium. "All those safe harbors are a disadvantage to the employers," Mr. Perretta said. "They're conservative estimates of affordable."
The rule could also create confusion for employees who try to buy insurance on an exchange, because none of these safe harbors will actually be used by the exchanges to determine whether the insurance offered by the company really is unaffordable and, therefore, whether the worker is entitled to a government-paid subsidy. Instead, the exchanges will rely on household income, which the employee will estimate, backed by the most recent tax return available.
The upshot is that, as the I.R.S. acknowledged in its proposed rule, there could be cases where an employer's offer of coverage would be treated as affordable for the purposes of the employer mandate but unaffordable when the worker seeks coverage on the exchange. In that event, the employer would get a pass. Though the employee would get the tax credits to buy individual insurance, the company would not have to pay the penalty that covers at least part of the cost of the subsidy. In addition, the safe harbors are voluntary. If a company is unhappy with the alternatives they offer, it can always attempt to calculate each employee's actual household income.
In any case, the business lobby - perhaps relieved that companies will not have to figure out how much money their employees' spouses are making - seems satisfied with what the I.R.S. has done. "The W-2 pay rule is a good objective standard that people can use," said J.D. Piro, a senior vice president in charge of the health law group at the benefits consulting company Aon Hewitt. "The employers' interest is in passing the test with the data that they have."
In the Affordable Care Act, Some Children Left Behind
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
The I.R.S. Interprets the Employer Mandate, and Businesses Have Questions
A Bakery Is Relieved to Have the Employer Mandate Delayed
Could Employers Use Immigrants to Avoid the Health Mandate?
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November 16, 2013 Saturday
Late Edition - Final
Health Rollout: Troubles and Fixes
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 18
LENGTH: 645 words
To the Editor:
Re ''In a Reversal, Obama Moves to Avert the Cancellation of Health Policies'' (front page, Nov. 15):
President Obama said early on that the Affordable Care Act would be tweaked and improved as needed. It is new territory, and in the end it will be great for this nation. Americans need to stop impatiently banging their spoons on their highchairs and realize that hard work is underway to fix the regrettable rollout problems.
Meanspirited Republicans and spineless Democrats in Congress need to rally behind the president and stop fretting about their re-elections. It is time to stand up for the Affordable Care Act. That goes for the ever-greedy health insurance industry as well.
Let's end the criticism and make this great legislation work for all Americans.
FRANK DiMARCO Portland, Ore., Nov. 15, 2013
To the Editor:
Oh goody, I can keep my horrible plan -- with its $10,000 deductible, with its almost never paying anything for any treatment (on a visit to a physician assistant to renew prescriptions, I just had my blood pressure taken, was billed $240 and the insurance company paid zero).
But I found a much better plan on the exchanges. And even without a subsidy, it's cheaper. It will get me through the next two years until I can get what every American should have: single-payer health insurance through Medicare.
RICHARD GRAYSON Apache Junction, Ariz., Nov. 15, 2013
To the Editor:
It is quite surprising that so many, including your newspaper, seem taken aback at the problems of implementing Obamacare. Universal health care is a public good from whose benefits nobody should be excluded. Markets fail in providing public goods because they do not ''care'' but instead look for the most efficient supply and use of goods and services.
Now what do you expect if market negotiation is combined with the ethics of social services for the poor? The resulting frictions should actually be welcomed as indicators of where to draw the line between those willing and able to pay for health care and those who have to rely on its provision by the government.
Most advanced nations have found the demarcation line after a lengthy process of trial and error. Give President Obama a chance to do this; after all, he cares.
PETER BARTELMUS New York, Nov. 15, 2013
The writer is a retired professor of economics at the University of Wuppertal in Germany.
To the Editor:
Re ''As Troubles Pile Up, a Crisis of Confidence'' (news analysis, front page, Nov. 15): Comparing President Obama's rollout of the Affordable Care Act to President Bush's response to Hurricane Katrina is a false equivalent if ever there was one.
Katrina was a natural disaster amplified by mankind's arrogance. To say the preparedness and response were lacking would be an understatement.
The Affordable Care Act is a well-intentioned law with great potential benefit. While the rollout has been far from smooth, let's not forget that the website component is perhaps the most complex ever assembled.
The administration could have been more realistic in managing people's expectations. Admittedly, the president could have been more forthright about who keeps their coverage. But the comparison to President Bush is unnecessary and unfair.
BRUCE ELLERSTEIN New York, Nov. 15, 2013
To the Editor:
What is really frightening is that because of the flawed rollout of the Affordable Care Act, President Obama's approval rating has dropped, people in his party are turning against him and the Republicans will have more ammunition to use against any progressive legislation that might benefit the American people.
Uninformed voters will support politicians who rail against this law, and their anger might carry over into the 2014 and 2016 elections, handing the Senate and perhaps the White House into radical conservative hands. I hope I will be wrong about this.
HOWARD SMITH Pasadena, Tex., Nov. 15, 2013
URL: http://www.nytimes.com/2013/11/16/opinion/health-rollout-troubles-and-fixes.html
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November 30, 2016 Wednesday
Late Edition - Final
Cabinet Choice Wrote Remake of Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1355 words
WASHINGTON -- In choosing Representative Tom Price of Georgia to be his health secretary, President-elect Donald J. Trump has signaled an undiminished determination to repeal President Obama's signature domestic achievement, the Affordable Care Act, and replace it with a health law that would be far less comprehensive.
And Mr. Trump is handing Republicans and their base voters what they have clamored for since the Affordable Care Act became law in 2010 -- a powerful force to reverse course.
Republicans were pleased.
''I can tell you where we're going to start: with a process to repeal and replace Obamacare,'' Senator Mitch McConnell of Kentucky, the majority leader, said Tuesday.
Mr. Price, an orthopedic surgeon from Atlanta's affluent northern suburbs, was one of the first lawmakers to draft a full replacement for the Affordable Care Act. His proposal would take health care in a fundamentally different direction, away from mandated coverage and care and toward a free-market approach, with fewer consumer protections and more freedoms for doctors.
''The president-elect has made it very clear: He wants the Congress, when they convene in early January, to take up the task of repealing and replacing Obamacare first,'' Vice President-elect Mike Pence said Tuesday on Fox News. He described Mr. Price as ''someone who literally, for the last half a dozen years, has been in the forefront of efforts, not only to repeal Obamacare, but put forward common sense, free-market solutions that will lower the cost of health insurance, without growing the size of government.''
Some 20 million uninsured people have gained coverage under the Affordable Care Act, reducing the nation's uninsured rate to 8.6 percent, the lowest on record, the Obama administration says. The Congressional Budget Office has not estimated the cost of Mr. Price's legislation or its effects on coverage, but opponents say the human cost would be steep.
The Price bill, the Empowering Patients First Act, would weaken many protections for consumers in the Affordable Care Act. The law, for example, prohibits insurers from denying coverage or charging higher rates because of a person's pre-existing medical conditions. Under the bill, this type of protection would be available to people who have maintained coverage in the past -- for example, people moving to the individual market from an employer's health plan.
The federal requirement for most Americans to have health insurance or pay a tax penalty would be eliminated, as would the requirement for larger employers to offer coverage. Billions of dollars that 31 states expect to receive for expanding Medicaid eligibility would also disappear.
Instead, Mr. Price would offer tax credits for the purchase of individual and family health insurance policies. The credits would increase as people grow older and are likely to need more medical care. He would use other tax breaks to coax more people into contributing to health savings accounts that could be used to help pay medical expenses. Such accounts are championed by conservatives as a way to slow the growth of health costs.
The bill would make it easier for doctors to defend themselves against medical malpractice lawsuits. Patients would have a heavier burden of proof if doctors could show that they followed ''clinical guidelines'' for the treatment of medical conditions.
And under the legislation, it would be easier for doctors to enter into private contracts with Medicare beneficiaries. Such contracts allow physicians to opt out of Medicare's strictures and charge more than the amounts normally allowed.
The bill would eliminate the federal health insurance exchange, through which millions of people have obtained subsidies for the purchase of insurance coverage. States could contract with private entities to set up websites that resemble HealthCare.gov, but only to provide information on insurance plans' prices and benefits and their networks of doctors and hospitals. The new websites could not directly enroll people in private plans or in Medicaid.
From his days as a Georgia state senator, Mr. Price, now 62, has been a voice for doctors, and if confirmed by the Senate, he could use his post as health secretary to protect fellow physicians in myriad ways. As health secretary, he would have real power, not only through his influence with Congress but also through the regulatory levers of the Centers for Medicare and Medicaid Services, a part of the Department of Health and Human Services.
His bill says that doctors would generally be ''exempt from the federal antitrust laws'' when they engage in contract negotiations with health insurance plans over the terms of their service. In many cases over the years, the federal government has accused doctors of violating antitrust laws in their dealings with insurers.
The legislation would also offer federal grants to states for ''high-risk pools'' to subsidize insurance for people who might otherwise have difficulty finding coverage in the open market because of ''the existence or history of a medical condition.''
Such pools have not worked so well in the past, and Douglas W. Elmendorf, a former director of the Congressional Budget Office who is now dean of the Kennedy School of Government at Harvard, expressed doubts about their effectiveness.
''High-risk pools sound clever,'' Mr. Elmendorf said Tuesday, ''but why would isolating the sickest people be expected to reduce the cost of insuring them?''
Mr. Price's bill would also allow insurers licensed in one state to sell policies to residents of other states, a change that Mr. Trump often advocated in the campaign.
Beyond the possible loss of coverage gains, Mr. Price's bill would be controversial for other reasons. One particularly contentious provision would limit the amount of tax-free coverage that workers could receive from their employers. The limits would be set at $8,000 for coverage of an individual employee and $20,000 for family coverage, with adjustments for inflation in later years.
Democrats are preparing for a fight. Senator Chuck Schumer of New York, the next minority leader, called Mr. Price ''far out of the mainstream of what Americans want when it comes to Medicare, the Affordable Care Act and Planned Parenthood.''
Mr. Trump said Tuesday that he had chosen Seema Verma, a health policy expert in Indiana, to be administrator of the Centers for Medicare and Medicaid Services. Working in state government and then as president of a consulting company, she helped Indiana expand Medicaid eligibility under the Affordable Care Act, with conservative policies that emphasized ''personal responsibility.''
Ms. Verma worked closely with Mr. Pence, the Indiana governor, who honored her this year with a Sagamore of the Wabash award, for Hoosiers who have made outstanding contributions to the state. She has won praise from health care providers and state legislators of both parties in Indiana, and has provided technical assistance to Medicaid officials in other states.
Mr. Price, who is chairman of the House Budget Committee and a member of the powerful Ways and Means Committee, has received generous campaign contributions from health care and related industries. In the latest cycle, he received $396,000 from health professionals, $181,900 from people who work for drug and other health-product companies, and more than $157,000 from people in the insurance business, according to the Center for Responsive Politics, an independent group that tracks money in politics.
In his campaign manifesto, Mr. Trump said Congress should give each state a lump sum of federal money -- a block grant -- for Medicaid, the program for lower-income people. Regardless of whether they can achieve that goal, Mr. Price and Ms. Verma would almost surely make it easier for states to obtain Medicaid waivers, the vehicle for a wide range of state innovations and experiments, which could include new eligibility rules and cost-sharing requirements.
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URL: http://www.nytimes.com/2016/11/29/us/tom-price-trump-health-secretary.html
LOAD-DATE: November 30, 2016
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GRAPHIC: PHOTO: Representative Tom Price, Donald J. Trump's choice for health secretary, offered a full replacement for the Affordable Care Act. (PHOTOGRAPH BY DREW ANGERER FOR THE NEW YORK TIMES) (A15)
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April 9, 2014 Wednesday
No Comment Necessary: Replacing the A.C.A. With...the A.C.A.?
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 178 words
HIGHLIGHT: Why it’s difficult to come up with the “replace” part of the “repeal and replace” slogan.
According to Talking Points Memo, there is "internal dissent" on whether the Republican Party should come up with an alternative to the Affordable Care Act. One congressional aide explained that it's difficult to come up a replacement, because it would probably end up looking a lot like the A.C.A.:
"If you want to say the further and further this gets down the road, the harder and harder it gets to repeal, that's absolutely true," the aide said. "As far as repeal and replace goes, the problem with replace is that if you really want people to have these new benefits, it looks a hell of a lot like the Affordable Care Act. ... To make something like that work, you have to move in the direction of the ACA. You have to have a participating mechanism, you have to have a mechanism to fund it, you have to have a mechanism to fix parts of the market."
Facts & Figures: Clueless on the 'Obamacare' Deadline
The Women on the Sidelines of the Hobby Lobby Case
No, 'Obamacare' Isn't Killing 2 Million Jobs
What's Behind the Declining Abortion Rate?
Looking Callous at the SOTU
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January 6, 2017 Friday 00:00 EST
Medicare and the Health Law;
Letter
SECTION: OPINION
LENGTH: 193 words
HIGHLIGHT: The Medicare Rights Center says Medicare recipients are at risk if the law is repealed.
To the Editor:
Re "The Coming Health Care Crisis" (editorial, Jan. 5):
Seniors and baby boomers should take note: The rush to repeal and delay the Affordable Care Act will harm them, too.
Like working-class Americans and their families, people with Medicare are at grave risk. Undoing the health law could increase their prescription-drug costs, eliminate access to preventive care, and roll back efforts that stabilized Medicare premiums and cost-sharing.
For people 55 to 64, more than 4.5 million could lose their coverage, and the number of those uninsured could double to nearly 20 percent. Vague replacement frameworks put forward in the past are all clear on at least one point: Insurers could charge even higher premiums than already permitted for this age group.
In fact, some such plans put no limits on how high premiums can go for people at these ages.
Before the Affordable Care Act, people under 65 called our help line every day desperate to find affordable coverage but learned that there was none. If the law is repealed, coverage will again be out of reach until they become eligible for Medicare.
JOE BAKER
President
Medicare Rights Center
New York
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(DealBook)
November 12, 2013 Tuesday
Fink Worries About Implications of Health Care Law
BYLINE: RACHEL ABRAMS
SECTION: BUSINESS
LENGTH: 260 words
HIGHLIGHT: Laurence Fink, the chief of BlackRock, said the financial effect of the Affordable Care Act was potentially more significant than the “noise about whether the website works or not.”
Many Americans are worried about how their health care will change under the Affordable Care Act. Laurence D. Fink, the chairman and chief executive of BlackRock, one of the largest money management firms, is worried about those worries.
"What does that mean to consumer behavior?" Mr. Fink said during DealBook's Opportunities for Tomorrow Conference on Tuesday. Healthcare.gov, the website where consumers can buy health coverage on the new consumer exchanges, has been something of a black eye for the Obama administration. Only a few hundred people reportedly signed up for coverage on the first day the site was up and running.
But Mr. Fink told the audience that the financial implications of the act were potentially more significant than the "noise about whether the website works or not."
"The reality is, health care represents 18 percent of our economy," he said.
Mr. Fink also said he was disappointed by the announcement in September by the Federal Reserve chairman, Ben S. Bernanke, that the government would not yet taper its bond buyback program, adding that he thought it should begin doing so "as soon as possible."
Mr. Fink said he didn't think the market would be "that upset" if the Fed began a $5 billion or $10 billion "thematic" tapering from its $85 billion a month program.
An earlier version of this article misspelled the given name of the chairman and chief executive of the money management firm BlackRock. It is Laurence Fink, not Lawrence.
After Fed's Announcement, Confusion and Relief on Wall Street
BlackRock Earnings Increase 32%
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February 25, 2014 Tuesday
Why Most Small-Business Owners Will See Premiums Rise Under A.C.A.
SECTION: BUSINESS; smallbusiness
LENGTH: 942 words
HIGHLIGHT: But how significant will those increases be?
A new report from the federal government that says more small employers will see premiums increase than fall under the Affordable Care Act appears to have put the Obama administration on the defensive once again. But the report is remarkable as much for what it reveals about the current state of the small-group market as for how it might look under Obamacare, as the law is commonly known.
The report was produced by the Centers for Medicare and Medicaid Services at the request of Congress, and it is largely an exercise in the theoretical. The Affordable Care Act outlaws premium discrimination based on a company's industry, the size of its group, or the health status and gender of its employees. The law also limits premium variation based on age, and the study assumes that when all these rules eventually take effect, all small companies and their workers will pay essentially the same rates.
Meanwhile, the agency estimates that today, under the current rules, two-thirds of small employers pay premiums that are below the average rate and one-third pay above-average premiums. Therefore, under an Affordable Care Act that is fully in place, two-thirds will see their premiums rise, and one-third will see premiums fall.
Of course, we have long known that some people would pay more for health insurance under Obamacare and some people would pay less. What is interesting is the skew: Why is it that two-thirds of employers, and employees, according to the study, have paid below-average premiums? Why isn't it closer to 50/50? The answer, according to the study, is that under the old system, companies that paid lower premiums because their employees posed smaller health risks were more likely to offer health insurance in the first place.
But according to Jonathan Gruber, a health economist at M.I.T. whose work was cited in the C.M.S. report, those companies' premiums were not as far below the average as the premiums of those businesses that insured older, less healthy employees were above the average. "The most expensive firms are very expensive, while the cheaper ones aren't that much cheaper," Mr. Gruber said. "So what that means is that while the cheaper firms will lose, they will lose by less than the most expensive firms gain. The 65/35 is still consistent with the overall roughly net zero result that the Congressional Budget Office, myself, and others have estimated."
It is also possible that companies that have not provided health insurance because it was too expensive may now be offered rates lower than what they were quoted in the past. The report estimates 18 million people get insurance through the small-group market, though not all will be affected by the new premium rules one way or the other. But according to the most recent figures from the Census Bureau, about 31 million people work for businesses with fewer than 50 employees. That means the current market leaves about 42 percent of small-business employees uninsured, and some of those would most likely find small-group insurance more affordable under the new rules.
The report did not quantify how much premiums would rise or fall. And it acknowledged that Congress asked the agency to study only three of the law's provisions and that other aspects of the law could affect how premiums change. "The impact could vary significantly depending on the mix of firms that decide to offer health insurance coverage," the study said. "In reality, the employers' decisions to offer coverage will be based on far more factors than the three that are focused on in this report."
Republicans in Congress took the opportunity presented by the report to attack the law. Representative Sam Graves, the Republican from Missouri who heads the House Small Business Committee, called it "one more in a long line of broken promises from President Obama and Washington Democrats."
Curiously, the Obama administration seemed restrained in its response, choosing not to address the new study directly. When asked for a comment, a spokeswoman for the Department of Health and Human Services, Joanne Peters, said only, "Since the Affordable Care Act became law, health care costs have been growing at the slowest rates on record and premiums are growing at less than one-half the pace seen a decade ago. The law is making it easier for businesses to offer coverage, just like it did in Massachusetts when employer coverage increased after reform passed."
Tom Daschle, the former Democratic majority leader in the Senate and President Obama's first nominee to lead the Department of Health and Human Services, bemoaned what he said was an increasingly one-sided debate. "There are so many ways to look at this," said Mr. Daschle, who is now a senior policy adviser to the law firm DLA Piper, of the C.M.S. report. For one thing, he said, the tax credits available to very small businesses that offer insurance will "change tremendously the way premiums are paid."
He went on to question why the administration had not responded more forcefully. "I think it's been a big mistake that we're not pushing back as hard as we can," he said. "There's an old saying attributed to Winston Churchill: a rumor gets halfway around the world before the truth gets its shoes on. That has happened over and over again with the Affordable Care Act."
Another Delay for Small-Business Health Exchanges? Depends on Whom You Ask.
Employer Mandate, Delayed by Paperwork (and Efforts to Reduce It)
Should a Bakery With More Than 50 Employees Offer Health Insurance?
Assessing Who Benefits From the Latest Rulings on the Employer Mandate
A Hotelier Corrects His Testimony on the Impact of the Affordable Care Act
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October 1, 2014 Wednesday
Late Edition - Final
U.S. Cannot Subsidize Health Plans in States With No Marketplace, a Judge Rules
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 610 words
WASHINGTON -- A federal district judge in Oklahoma dealt a blow to the Affordable Care Act on Tuesday, ruling that the federal government could not subsidize health insurance in three dozen states that refused to establish their own marketplaces. This appears to increase the likelihood that the Supreme Court will ultimately resolve the issue.
Federal appeals courts in Washington and in Richmond, Va., split on this question in July.
Judge Ronald A. White of the Federal District Court in Muskogee, Okla., said Tuesday that a rule issued by the Obama administration allowing subsidies in the 36 states was arbitrary and capricious, in excess of statutory authority or simply ''an invalid implementation'' of the 2010 health care law.
The ruling, if ultimately upheld, could cut off financial assistance for more than 4.5 million people who were found eligible for subsidized insurance in the federal exchange, or marketplace. However, the judge stayed the effect of his decision to allow for an appeal, and Emily Pierce, a Justice Department spokeswoman, said the federal government would file one.
Subsidies, in the form of tax credits, are at the heart of the health care law. Without them, many consumers would be unable to afford coverage.
Judge White noted that the law authorized subsidies specifically for insurance bought ''through an exchange established by the state.''
The Obama administration argued that it was ''standing in the shoes'' of states when it established exchanges for states that had failed to do so.
The judge rejected this reading of the law, saying it ''does not appear to comport with normal English usage.'' The word ''state,'' he said, does not and cannot mean the federal government.
The Obama administration said Congress intended for subsidies to be available in all states, regardless of who established their exchanges. To deny subsidies in the federal exchange would eviscerate the law, the administration said.
Judge White, who was appointed by President George W. Bush in 2003, insisted that his ruling would not gut or destroy anything. ''On the contrary,'' he said, ''the court is upholding the act as written. Congress is free to amend the Affordable Care Act to provide for tax credits in both state and federal exchanges, if that is the legislative will.''
Vague notions of a statute's ''basic purpose'' cannot overcome the words of the law itself, he said.
The case, Oklahoma v. Burwell, was filed by the state against the federal government.
The Oklahoma attorney general, E. Scott Pruitt, called the decision ''a victory for the rule of law'' and said it showed that ''the administration can't rewrite the Affordable Care Act by executive fiat.''
''The administration and its bureaucrats in the Internal Revenue Service,'' he said, ''handed out billions in illegal tax credits and subsidies and vastly expanded the reach of the health care law because they didn't like the way Congress wrote the Affordable Care Act.''
In its 2-to-1 ruling in July, a panel of the United States Court of Appeals for the District of Columbia Circuit struck down the rule on subsidies, issued by the Internal Revenue Service. The court recently vacated that decision and said that the case should be heard in December by the full court, not just the three-judge panel.
Plaintiffs in the Virginia case have not asked for a rehearing in the circuit court there, but have appealed to the Supreme Court, where they apparently believe that they have a better chance of success.
A fourth case, filed by the State of Indiana and local school districts, is pending in the Federal District Court in Indianapolis, which plans to hear arguments this month.
URL: http://www.nytimes.com/2014/10/01/us/us-cannot-subsidize-health-plans-in-states-with-no-marketplace-a-judge-rules.html
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January 4, 2017 Wednesday 00:00 EST
Republicans' 4-Step Plan to Repeal the Affordable Care Act
BYLINE: ROBERT PEAR
SECTION: US
LENGTH: 1293 words
HIGHLIGHT: Though much remains unclear, a determined Republican president and Congress can gut President Obama's signature accomplishment.
WASHINGTON - Vice President-elect Mike Pence and the top Republicans in Congress made clear on Wednesday, more powerfully and explicitly than ever, that they are dead serious about repealing the Affordable Care Act.
How they can uproot a law deeply embedded in the nation's health care system without hurting some of the 20 million people who have gained coverage through it is not clear. Nor is it yet evident that millions of Americans with pre-existing medical conditions will be fully protected against disruptions in their health coverage.
But a determined Republican president and Congress can gut the Affordable Care Act, and do it quickly: a step-by-step health care revolution in reverse that would undo many of the changes made since the law was signed by President Obama in March 2010.
Step 1: Defang the filibuster
The Senate intends to pass a budget resolution next week that would shield repeal legislation from a Democratic filibuster. If the Senate completes its action, House Republican leaders hope that they, too, can approve a version of the budget resolution next week. Whether they can meet that goal is unclear.
The resolution contains seemingly innocuous language, instructing four committees that control health care policy - two in the Senate, two in the House - to draft legislation within their jurisdiction that would cut at least $1 billion from the deficit over 10 years. But that language has real teeth. The legislation produced to meet those instructions can pass the Senate with a simple majority - 51 votes if all senators are present - obliterating the power of the Democratic minority to block it.
Those four committees would have just a few weeks, until Jan. 27, to produce legislation repealing major provisions of the Affordable Care Act. House Republicans have some practice at this, because they have voted more than 60 times since 2011 to repeal some or all of the law.
The budget blueprint will guide Congress but will not be presented to the president for a signature or veto.
Step 2: Add the details
The committees - House Energy and Commerce, House Ways and Means, Senate Finance, and Senate Health, Education, Labor and Pensions - will quickly assemble legislation intended to eviscerate the health care law.
The repeal legislation will be in the form of a reconciliation bill, authorized by the Congressional Budget Act of 1974. Such bills can be adopted under special fast-track procedures. But Senate rules generally bar the use of those procedures for measures that have no effect on spending or revenue. So the legislation, as now conceived, would probably leave the most popular provisions of the health law intact, such as the prohibition on insurers' denying coverage to people with pre-existing conditions.
Instead, the legislation would:
" Eliminate the tax penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.
" Eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid.
" Repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.
It could also repeal some of the taxes and fees that help pay for the expansion of coverage under the Affordable Care Act. But some Republicans have indicated that they may want to use some of that revenue for their as-yet-undetermined plan to replace the health care law.
The 2010 law imposed taxes and fees on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices, among others. Republicans have not said for sure which taxes they will scrap and which they may keep.
Republicans say they will delay the effective date of their repeal bill to avoid disrupting coverage and to provide time for them to develop alternatives to Mr. Obama's law. They disagree over how long the delay should last, with two to four years being mentioned as possibilities.
Step 3: The new president's role
Within days of taking office, President-elect Donald J. Trump plans to announce executive actions on health care. Some may undo Obama administration policies. Others will be meant to stabilize health insurance markets and prevent them from collapsing in a vast sea of uncertainty.
"We are working on a series of executive orders that the president-elect will put into effect to ensure that there is an orderly transition, during the period after we repeal Obamacare, to a market-based health care economy," Mr. Pence said at the Capitol on Wednesday.
He did not provide details, and Trump transition aides said they had no information about the executive orders. But some options are apparent. The federal government could continue providing financial assistance to insurance companies to protect them against financial losses and to prevent consumers' premiums from soaring more than they have in the last few years.
Step 4: Find a replacement
Even as they move full speed toward gutting the existing health law, Republicans are scrambling to find a replacement. At the moment, they have no consensus.
Mr. Pence said on Wednesday that the replacement would probably encourage greater use of personal health savings accounts and make it easier for carriers to sell insurance across state lines. Also, he said, it would encourage small businesses to band together and buy insurance through "association health plans" sponsored by business and professional organizations.
Some type of subsidy or tax credit for consumers, to help defray the cost of premiums, is also likely. States would have more authority to set insurance standards, and the federal government would have less.
Mr. Trump has also endorsed the idea of state-run "high-risk pools" for people with pre-existing conditions who would otherwise have difficulty finding affordable coverage.
Many experts have said that repealing the health law without a clear plan to replace it could create havoc in insurance markets. Doctors, hospitals and insurance companies do not know what to expect.
Without an effective requirement for people to carry insurance, and without subsidies to buy it, supporters of the law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.
Democrats in Congress say they will do everything they can to thwart Republican efforts to dismantle the Affordable Care Act. They plan to dramatize their case by publicizing the experiences of people whose lives have been saved or improved by the law.
In the Senate next week, Democrats will demand votes intended to put Republicans on record against proposals that could protect consumers. Defenders of the law also hope to mobilize groups like the American Cancer Society and the American Heart Association to speak up for patients.
The Senate Democratic leader, Chuck Schumer of New York, and the House Democratic leader, Nancy Pelosi of California, are encouraging their colleagues to organize rallies around the country on Jan. 15 to oppose the Republicans' health care agenda.
And to buttress their case, Democrats are compiling statistics from the White House and from researchers at liberal-leaning groups like the Center on Budget and Policy Priorities, the Commonwealth Fund and the Urban Institute, which warn of catastrophic consequences if the law is repealed.
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PHOTO: Senator Mitch McConnell, right, with Vice President-elect Mike Pence on Wednesday. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A12)
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March 5, 2015 Thursday
Late Edition - Final
The Fate of American Health Care
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 541 words
In 2012, the chief justice of the United States, John Roberts Jr., saved the Affordable Care Act by a single, surprising vote. On Wednesday morning, the chief justice was again expected to hold the decisive vote as the Supreme Court heard extended oral argument in the latest assault on President Obama's signature health care law.
The case, King v. Burwell, will determine the fate of legislation that has transformed the American health care system. But the argument provided few solid clues to how the justices will rule.
The chief justice remained virtually silent for the entire argument, while most of the others took predictable positions in questioning the government or the challengers. The surprise this time came from Justice Anthony Kennedy, who had voted with the dissenters from the 2012 decision that upheld the Affordable Care Act and appeared to have no interest in protecting the law.
Nevertheless, Justice Kennedy flagged a ''serious constitutional problem'' with the current challenge, which focuses on a single phrase -- ''established by the State'' -- embedded deep in a subsection of the act.
Michael Carvin, the plaintiffs' lawyer, had been arguing -- against all evidence and logic -- that when Congress passed the act in 2010, it simultaneously undermined the law's central goal of affordable health care for all Americans by supposedly denying tax-credit subsidies to all residents in the 34 states where the federal government runs the health care exchange.
A vast majority of the more than 11 million Americans signed up under Obamacare are eligible for these subsidies, and would be unable to afford health care without them.
The absence of these subsidies, in other words, would mean the collapse of the insurance markets in those 34 states -- which did not for various reasons set up their own exchanges -- and costs for individuals would be even higher than they were before the law passed.
This is what seemed to concern Justice Kennedy, who has often expressed a solicitude for states' rights: that if the law made subsidies available only on state exchanges, that would amount to the federal government coercing states to establish exchanges or face the implosion of their health insurance markets.
As Justice Kennedy described the scenario under the plaintiffs' reading of the law, ''The states are being told: Either create your own exchange, or we'll send your insurance market into a death spiral.''
Abbe Gluck, a Yale professor who specializes in health law, wrote last week that this would amount to ''the greatest bait and switch on state governments in history.''
After Justice Antonin Scalia tried to dismiss Justice Kennedy's point, Justice Kennedy repeated himself: ''I think the court and the counsel for both sides should confront the proposition that your argument raises a serious constitutional question,'' he said.
When Mr. Carvin protested that the government's brief had not made this argument, Justice Kennedy responded, ''Sometimes we think of things the government doesn't.''
It was a small but encouraging sign that a majority of the court may be prepared to avoid a ruling that would essentially destroy Obamacare -- which is precisely what the challengers hope to do.
URL: http://www.nytimes.com/2015/03/05/opinion/the-supreme-court-and-the-fate-of-american-health-care.html
LOAD-DATE: March 5, 2015
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The New York Times
March 5, 2015 Thursday
Late Edition - Final
The Fate of American Health Care
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 541 words
In 2012, the chief justice of the United States, John Roberts Jr., saved the Affordable Care Act by a single, surprising vote. On Wednesday morning, the chief justice was again expected to hold the decisive vote as the Supreme Court heard extended oral argument in the latest assault on President Obama's signature health care law.
The case, King v. Burwell, will determine the fate of legislation that has transformed the American health care system. But the argument provided few solid clues to how the justices will rule.
The chief justice remained virtually silent for the entire argument, while most of the others took predictable positions in questioning the government or the challengers. The surprise this time came from Justice Anthony Kennedy, who had voted with the dissenters from the 2012 decision that upheld the Affordable Care Act and appeared to have no interest in protecting the law.
Nevertheless, Justice Kennedy flagged a ''serious constitutional problem'' with the current challenge, which focuses on a single phrase -- ''established by the State'' -- embedded deep in a subsection of the act.
Michael Carvin, the plaintiffs' lawyer, had been arguing -- against all evidence and logic -- that when Congress passed the act in 2010, it simultaneously undermined the law's central goal of affordable health care for all Americans by supposedly denying tax-credit subsidies to all residents in the 34 states where the federal government runs the health care exchange.
A vast majority of the more than 11 million Americans signed up under Obamacare are eligible for these subsidies, and would be unable to afford health care without them.
The absence of these subsidies, in other words, would mean the collapse of the insurance markets in those 34 states -- which did not for various reasons set up their own exchanges -- and costs for individuals would be even higher than they were before the law passed.
This is what seemed to concern Justice Kennedy, who has often expressed a solicitude for states' rights: that if the law made subsidies available only on state exchanges, that would amount to the federal government coercing states to establish exchanges or face the implosion of their health insurance markets.
As Justice Kennedy described the scenario under the plaintiffs' reading of the law, ''The states are being told: Either create your own exchange, or we'll send your insurance market into a death spiral.''
Abbe Gluck, a Yale professor who specializes in health law, wrote last week that this would amount to ''the greatest bait and switch on state governments in history.''
After Justice Antonin Scalia tried to dismiss Justice Kennedy's point, Justice Kennedy repeated himself: ''I think the court and the counsel for both sides should confront the proposition that your argument raises a serious constitutional question,'' he said.
When Mr. Carvin protested that the government's brief had not made this argument, Justice Kennedy responded, ''Sometimes we think of things the government doesn't.''
It was a small but encouraging sign that a majority of the court may be prepared to avoid a ruling that would essentially destroy Obamacare -- which is precisely what the challengers hope to do.
URL: http://www.nytimes.com/2015/03/05/opinion/the-supreme-court-and-the-fate-of-american-health-care.html
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The New York Times
November 28, 2016 Monday 00:00 EST
The G.O.P. and Health Care Chaos;
What's at Stake
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 689 words
HIGHLIGHT: Donald Trump and Congress want to repeal the Affordable Care Act, but they have no good ideas for replacing it.
What will happen if President-elect Donald Trump and Republicans in Congress carry out their pledge to repeal the Affordable Care Act, the 2010 health reform law? By most estimates, upto 22 million people, many of them poor or older Americans, will lose their health insurance.
Mr. Trump seems to recognize this would be disastrous - to an extent. Since the election, he has said that he wants to keep the part of the law that prohibits insurance companies from discriminating against people with pre-existing conditions. Without this provision, insurers can deny those customers coverage, charge them exorbitant rates or refuse to cover treatment for those conditions.
But Mr. Trump and other Republicans are delusional if they think that they can preserve that provision while scrapping the rest of the health care law. Insurers are able to offer policies to people with pre-existing conditions because the law greatly expands the number of people who are insured, thus spreading the costs of treating people with chronic conditions over a larger number of paying customers.
The law provides subsidies to help individuals and families buy policies on government-run online health exchanges (those who do not buy insurance are required to pay a tax penalty). Take away or greatly reduce that benefit and millions won't be able to afford the plans, and many insurers will simply stop selling policies or will charge individuals and families much higher rates. The law also expanded Medicaid by financing state programs with federal money. Take away that money, and many states will no longer be able to provide care to millions of poor families.
Republicans have said that Congress could vote early next year to repeal the Affordable Care Act but delay the actual end of the law for a year or two. In theory, that would allow lawmakers to come up with a workable replacement while putting off the consequences of repeal.
But any vote to repeal the law would almost certainly cause insurers - which know they won't be able to depend on the federal government in the future - to start pulling their plans from the online marketplaces for 2018 coverage, kicking millions off coverage. State and local governments will have to start planning to increase spending on public hospitals and charity medical care. Consider this: Uncompensated care at hospitals declined by $7.4 billion in 2014 after most major provisions of the law kicked in, according to the Department of Health and Human Services. Those costs would most likely go right back up.
The House speaker, Paul Ryan, and Republican policy experts have sketched out a variety of replacements for the law, but have not coalesced around one plan. All of them would reduce government spending and slash coverage.
One idea backed by Mr. Ryan would create a government-run high-risk pool to help pay for the medical care of people with major health problems who don't have insurance. But previous state and federal high-risk pools did not cover most of the people with pre-existing conditions and suffered large losses, according to the Kaiser Family Foundation. Other Republican ideas include expanding the use of health savings accounts, which would primarily benefit wealthy families that can afford to sock away substantial amounts for future health problems.
Those complexities explain why Senator Lamar Alexander, the Tennessee Republican who leads the Health, Education, Labor and Pensions Committee, recently said it would "take several years" to fully replace the Affordable Care Act. Though the law is not perfect, it has greatly increased access to medical care and has made some parts of the health system more efficient by, for example, increasing the use of preventive services.
In discussing the repeal of the law during the campaign, Mr. Trump said, "There will be a certain number of people who will be on the street dying, and as a Republican, I don't want that to happen." He might start by following the maxim to "first, do no harm."
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April 5, 2017 Wednesday
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Trump Struggles to Win All Sides on Health Bill
BYLINE: By ROBERT PEAR and THOMAS KAPLAN; Michael D. Shear contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1039 words
WASHINGTON -- The White House stepped up its push on Tuesday to revive legislation to repeal the Affordable Care Act by placating the most conservative House members, but the effort risked alienating more moderate Republicans whose votes President Trump needs just as much.
Vice President Mike Pence met for about two hours on Tuesday night with lawmakers, including leaders of three groups of House Republicans. But lawmakers leaving the conclave in the basement of the Capitol said that no deal had been reached and that talks would continue on Wednesday.
''It was a very good exchange of ideas, with concerns that represent the broad spectrum of our conference,'' said Representative Mark Meadows, Republican of North Carolina and the chairman of the conservative House Freedom Caucus. ''There were no agreements tonight, and no agreements in principle,'' he added.
Mr. Pence has been meeting continually with House Republicans this week to rework and resuscitate the repeal bill that collapsed on the House floor on March 24. But the House speaker, Paul D. Ryan, acknowledged that changes intended to gain support on one side of the House Republican Conference could lose votes on another.
''It's important that we don't just win the votes of one caucus or one group, but that we get the votes and the consensus of 216 of our members,'' Mr. Ryan said.
In negotiations with members of the Freedom Caucus this week, administration officials have discussed allowing states to opt out of two bedrock requirements in the Affordable Care Act. One requires insurers to cover a standard minimum package of benefits, known as essential health benefits. The other generally requires insurers to charge the same price to people of the same age who live in the same geographic area, with a possible surcharge for tobacco users. Under this provision, known as community rating, insurers cannot vary premiums based on a person's health status, insurance claims history or gender.
Mr. Meadows said earlier Tuesday that he was pleased the administration was willing to eliminate more of the mandates in the Affordable Care Act, which Republicans have been trying to repeal ever since it was signed by President Barack Obama in 2010.
''Lower premiums have to be our first and only priority,'' Mr. Meadows said. ''By repealing community rating and the essential health benefits, it allows for lower premiums across the board.''
But Mr. Meadows said Freedom Caucus members wanted to see the language that would be added to the repeal bill before promising to vote for it, and no such language was made available at the meeting on Tuesday night.
At the same time, more moderate Republicans were expressing concern for other reasons. Administration officials say they want to preserve one of the most popular provisions of the Affordable Care Act, which bars insurers from denying coverage to people with pre-existing medical conditions. But without a requirement for some form of community rating, insurers could effectively do that, simply by increasing the cost of policies for sick or risky customers.
''I don't think we will have something that eliminates community rating,'' said Representative Tim Murphy of Pennsylvania, a member of the caucus of moderate Republicans known as the Tuesday Group. ''That just can't be.''
Mr. Murphy, a psychologist, has successfully championed legislation to improve treatment for mental illness and drug abuse, including opioid addiction. He said he wanted to be sure that any changes to the bill protected mental health care and treatment for substance abuse disorders, as well as maternity care -- benefits that are guaranteed under the Affordable Care Act.
Mr. Ryan and the White House tried to play down expectations of a breakthrough, saying the talks on a new health care bill were at a preliminary, conceptual stage.
Sean Spicer, the White House press secretary, said the vice president and the chief of staff, Reince Priebus, were ''very optimistic'' about the possibility of developing a health care bill that could win a majority of votes in the House.
''The president would like to see this done,'' Mr. Spicer said. ''If we can get a deal and it gets to those votes -- which, again, I'm not going to raise expectations, but there are more and more people coming to the table with more and more ideas about how to grow that vote.''
New York adopted community rating under a state law in the 1990s, and the policy caused serious problems in the individual insurance market, but state officials have come to accept it.
Representative Tom Reed, a New York Republican who supported the original version of the repeal bill last month, said on Tuesday: ''Community rating is one of those things that is a very significant reform in the Affordable Care Act. I appreciate the states' rights argument, but recognize that there is a reason behind community rating and the benefit that it brings to the insurance reforms.''
Democrats say that relaxing federal standards for benefits and rates would, in effect, eviscerate protections for people with pre-existing conditions.
And some Republicans appear to share that concern. Allowing states to opt out of the federal requirements for minimum benefits and community rating ''could greatly erode the safeguards Obamacare put in place for those with pre-existing conditions,'' said Representative Leonard Lance, Republican of New Jersey, who opposed the earlier House repeal bill and has not moved from that position.
Representative Chris Collins of New York, a Trump ally and member of the Tuesday Group, said he too was concerned about allowing states to obtain waivers from the community rating requirement.
''It's one thing if you have car crashes and you pay higher car insurance,'' Mr. Collins said. ''Health is a different animal.''
The version of the repeal bill that went to the House floor last month died after Republican leaders, in a bid for conservative support, agreed to eliminate federal standards for minimum benefits. Under the proposal now under consideration, states could obtain waivers from the federal requirements.
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URL: http://www.nytimes.com/2017/04/04/us/politics/president-trump-health-care.html
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June 23, 2015 Tuesday
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Medical Insurance Is Good for Financial Health
BYLINE: By AUSTIN FRAKT; .
SECTION: Section A; Column 0; Foreign Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 689 words
People who have health insurance have less health-related financial stress. That's a not-so surprising finding from a recent survey from the Centers for Disease Control and Prevention.
There's good reason to expect the Affordable Care Act to reduce financial strain. Exposure to health care costs fell for those who gained coverage, as it has for those whose coverage became more generous, too.
But even those families whose health insurance coverage didn't change may have benefited. In 2013, 32.2 percent of uninsured families had problems paying medical bills, but that dropped to 31.2 percent in 2014. There may have been less need for people to pitch in if their formerly uninsured family members obtained coverage.
Another possibility is that those who obtained coverage may have been in a better position to financially assist family members who still lacked it. This could partly explain why the financial condition of even the uninsured improved after the Affordable Care Act's coverage expansion. Other factors, like an improving economy, could also help explain the changes.
The C.D.C. looked at data from more than 370,000 people collected through the National Health Interview Survey. It found that in the six months after the introduction of the Affordable Care Act in January 2014, the percentage of people under age 65 who were in families having problems paying medical bills was lower than it had been before -- 17.8 percent vs. 19.4 percent in 2013. Smaller reductions in financial strain from medical bills had occurred in prior years, perhaps because of slow improvements in the economy after the end of the Great Recession.
The C.D.C.'s findings are consistent with another recent survey by the Commonwealth Fund, as reported by my colleague Margot Sanger-Katz. It found that the percentage of adults experiencing trouble with a medical bill or medical debt declined to 35 percent in 2014 from 41 percent in 2012.
Coverage expansions that predate the Affordable Care Act were also associated with reductions in health-related financial difficulty. After Oregon expanded its Medicaid program by lottery in 2008, out-of-pocket medical expenses exceeding 30 percent of income fell more than 80 percent, according to analysis published in The New England Journal of Medicine.
Massachusetts' 2006 coverage expansion law, which resembles the Affordable Care Act in many respects, was also associated with better financial conditions for families, a Federal Reserve Bank of Chicago study found. For instance, when coverage expanded, the two-year bankruptcy rate fell by 20 percent, credit balance past due fell by 22 percent, fraction of debt past due fell by 10 percent and credit scores improved by 0.4 percent.
Despite the financial relief that accompanies coverage expansion, high medical costs remain for many families. Some families covered by exchange plans could face out-of-pocket costs as high as 40 percent of their incomes. More than a fifth of Americans have medical debt on their credit reports. A recent Commonwealth Fund survey found that 23 percent of insured Americans were ''underinsured,'' meaning their medical expenses were above 10 percent of household income the last year (5 percent if very low income) or their deductibles more than 5 percent of income.
This is also unsurprising. Deductibles and other cost sharing can be high for some plans. And they're growing for employer-sponsored plans, cutting against the financial security health insurance might otherwise offer.
Yet the evidence is clear. Though it doesn't offer complete financial security to everyone, health insurance expansion has decreased financial strain. Financial security, after all, is the point of insurance. Though we might expect more from health insurance expansion -- like improvements in health as well -- at least it reduces financial strain, even if incompletely.
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This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2015/06/23/upshot/medical-insurance-is-good-for-financial-health-too.html
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October 4, 2013 Friday
Dealing With Drafting Errors in the Health Care Law
BYLINE: PHILLIP SWAGEL
SECTION: BUSINESS; economy
LENGTH: 1428 words
HIGHLIGHT: Two unintended consequences of the Affordable Care Act, affecting coverage for Congressional staff members and millions of moderate-income families, show the difficulty of remedying legislative flaws in the current political environment, an economist writes.
Phillip Swagel is a professor at the School of Public Policy at the University of Maryland and was assistant secretary for economic policy at the Treasury Department from 2006 to 2009.
In legislation as mammoth as the two bills that together constitute Obamacare, it is not surprising to find drafting errors in which the text of the law signed by President Obama does not accomplish the intent of Congress. The desirable response to such errors is for new legislation to be enacted to correct the mistake. With the Affordable Care Act at the center of the current legislative stalemate, however, the possibility for such changes seems remote. Indeed, it is difficult to imagine opening up the law to just minor changes at any point - political forces might well lead members of Congress to seek large-scale changes, whether to gut the law or to expand it to cover some of the 30 million people projected by the Congressional Budget Office to be uninsured in 2016 even after the law has been in effect for several years.
With political reality affecting even narrow legislative fixes favored by both parties, it is fascinating to consider the different treatment by the Obama administration of two salient drafting errors in the president's signature legislative accomplishment. One error in the legislation, discussed recently in Economix, would make Congressional staff members pay thousands of dollars more for their health insurance than was intended. This situation was addressed by the Office of Personnel Management through a rule change of dubious legality reportedly made under pressure from the White House, which in turn was responding to pressure from both sides of the Congressional aisle.
A second error in the health care law, involving the calculation of the level of insurance costs that are affordable, is projected to leave millions of people with low to moderate incomes unable to qualify for government subsidies to purchase health insurance. As a result, many people who were clearly meant to be covered will remain uninsured. In this second instance involving people with less power and lower incomes than those on Capitol Hill, the Obama administration is implementing the law as written, even though this surely does not reflect the administration's policy preference or Congressional intent.
As explained by the Congressional Research Service, there are special procedures in the House and Senate for dealing with changes that are technical in nature when a bill has been "enrolled" after positive votes in the House and Senate but not yet signed into law. Once the president has used his pen to turn a bill into law, however, new legislation is required to fix mistakes.
Legislation to make "technical corrections" has become relatively infrequent as Congressional partisanship has mounted over the decades, but it is still done to fix minor legislative glitches (the word "glitch" is a familiar presence in anything written about Obamacare these days). Public Law 110-244, for example, was enacted on June 6, 2008, to make technical corrections to a 2005 transportation funding bill. In addition to providing money for the "bridge to nowhere," the original legislation included earmarks for projects that by 2008 no longer existed. Among other things, the corrections bill redirected those funds.
Such an approach of a technical corrections bill seems natural to fix the drafting error affecting the Congressional staff. As discussed in detail by the health policy expert Doug Badger, the language of the health care law requires Congressional employees to obtain health insurance through an exchange created by the law, but other parts of the federal legal code restrict the ability of the federal government to pay the usual employer share for group insurance programs approved by the Office of Personnel Management. The complication is that the policies in the new exchanges are individual plans, not group, and they are not approved by the personnel office.
A straightforward reading of the law thus means that Congressional staff members, starting in January 2014, will have to obtain insurance through the Affordable Care Act but pay for it on their own without the normal contribution from their employer - Congress. This would be a multi-thousand-dollar income hit for those affected. Some could presumably switch to coverage offered by their spouse's employer, but many others would potentially feel the pain, giving rise to concerns over a potential brain drain of Congressional staff members finding other employment.
This was clearly a drafting error and not what Congress intended. A recent Politico article reported that the federal personnel office initially ruled that Congressional staff members would not be eligible for the subsidies, and then changed this decision under pressure from the White House (and thus indirectly from Congress).
A second drafting error in the Affordable Care Act will limit the eligibility of millions of moderate-income families to receive subsidies to help pay for insurance policies in the new exchanges (once the glitches are worked out). As explained in The Times, the health care law provides subsidies for people with low and middle incomes to obtain insurance through a government-run exchange. To preserve the employer-based insurance system, however, these subsidies are available only for people who cannot obtain affordable coverage from their employer.
The glitch arises because affordable insurance is based on the cost of individual coverage offered by an employer, which is considerably less expensive than family coverage. Families with moderate incomes could then face a situation in which they can afford individual insurance for the employee and thus do not qualify for subsidies, but cannot afford family coverage. Indeed, research by Richard Burkhauser, Sean Lyons, and Kosali Simon of Cornell University and Indiana University found that nearly four million dependents would be ineligible for subsidies as a result of the legislative problem.
A natural solution analyzed by researchers at the University of California, Berkeley, would be to split the determination of eligibility for insurance subsidies so that family members could receive subsidies to purchase coverage in the exchanges in the instances in which the worker obtained affordable individual coverage through an employer. The administration determined, however, that this approach was outside the boundaries of the legislative text - a decision described by The Times's health reporter as a "cramped reading of the law" but by others as simply following it. As noted by The Times's editorial board, this outcome "undercuts the basic goal of health care reform - to expand the number of insured people and make their coverage affordable."
The unfairness of the situations discussed above is twofold. The first inequity is that the drafting errors in the legislation defeat the evident intent of Congress. People are harmed by the errors - potentially millions of spouses and children will not have health insurance when they were meant to.
The second dimension of unfairness relates to the exceptional treatment of Congressional staff members. With the affordability issue, the administration appears to have faithfully executed the law, just as President Obama swore in his inaugural oath. Congressional staff members of both parties are dedicated public servants who deserve proper compensation, including the employer contribution to health insurance that is normal in the American system. But it is deeply unfair that this is being accomplished by an administrative decision that sets aside the law, even if done with the connivance of Congress.
It should be possible for the larger (and incredibly heated) debate over the merits of Obamacare to proceed even while specific flaws in the legislation are addressed to avoid unintended harms to thousands of Congressional employees or millions of vulnerable families. I write that without making a judgment about the larger questions surrounding the Affordable Care Act. Indeed, I support the idea of expanding insurance coverage but believe the approach taken by the Obama administration is deeply flawed (a subject for a future column). And yet, in today's political climate, addressing these unintended harms is not possible, with fault to be assigned at both ends of Pennsylvania Avenue.
How to Gut Obamacare
Health Coverage Worthy of a Senator
Remember Sequestration?
The Path to Complexity on the Health Care Act
A Health Care Fight That Punishes Federal Workers
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(Economix)
May 31, 2013 Friday
Affordable Care Act Could Be Good for Entrepreneurship
BYLINE: CATHERINE RAMPELL
SECTION: BUSINESS; economy
LENGTH: 516 words
HIGHLIGHT: The health care law is expected to produce a sharp increase in self-employment next year because of access to insurance on the individual market, according to a new report.
The Affordable Care Act is expected to produce a sharp increase in entrepreneurship next year, according to a new report from the Robert Wood Johnson Foundation, the Urban Institute and Georgetown University's Health Policy Institute. The number of self-employed people is expected to rise by 1.5 million - a relative increase of more than 11 percent - as a direct result of the health care overhaul.
One major barrier to entrepreneurship in the United States - beside the usual risks involved with starting a company - is that it has been difficult to get health insurance on the individual market. Those who do end up founding or joining a start-up are often able to do so because they have a spouse with employer-sponsored insurance, or because they are keeping a day job with a bigger company. (This was the case, for example, for most of the people involved with Leap2, a Kansas City start-up that I profiled last fall.)
Economists have looked at whether this insurance-related job lock is deterring self-employment and the formation of new businesses, and the data suggest it is. A Journal of Health Economics paper, for example, found that business ownership rates jumped sharply from just under age 65 to just over age 65, when people become newly eligible for Medicare. Using Current Population Survey data, the same paper also found that wage and salary workers are more likely to start businesses from one year to the next if they have a spouse with employer-based insurance.
A working paper from the Upjohn Institute looked at a change in the law in New Jersey that expanded access to individual health insurance. It found that the law seemed to increase self-employment, particularly among "unmarried, older, and observably less-healthy individuals."
The report released Friday applies those findings to a model of what will happen in 2014, based on the Affordable Care Act's provisions for "universal availability of non-group coverage, the financial assistance available for it, and other related market reforms." The authors also adjusted their numbers depending on the access that residents of various states already have to individual health insurance. (Vermont, for example, already has a statute that allows the self-employed to obtain small group coverage.) Over all, they found, the ranks of the self-employed are likely to rise 11.5 percent, from about 13.1 million to 14.6 million. A table with their state-by-state estimates is below.
By the way, the paper does not mention this, but the same forces that will make it easier for workers to become self-employed may also make it easier for workers to retire early. I have heard anecdotally about people in their late 50s or early 60s who would like to retire but can't do so because they're basically uninsurable (for now) on the individual market; I wonder if we'll notice a wave of retirements in this age group come 2014.
Massachusetts Employees Will Keep Their Health Plans
Patterns of Changes in Health Insurance
Health Coverage Worthy of a Senator
Hammurabi's Code and U.S. Health Care
Small Companies and the Affordable Care Act
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December 3, 2016 Saturday
Late Edition - Final
A G.O.P. Plan on Health Act: Rescind Slowly
BYLINE: By ROBERT PEAR, JENNIFER STEINHAUER and THOMAS KAPLAN
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1328 words
WASHINGTON -- Republicans in Congress plan to move almost immediately next month to repeal the Affordable Care Act, as President-elect Donald J. Trump promised. But they also are likely to delay the effective date so that they have several years to phase out President Obama's signature achievement.
This emerging ''repeal and delay'' strategy, which Speaker Paul D. Ryan discussed this week with Vice President-elect Mike Pence, underscores a growing recognition that replacing the health care law will be technically complicated and could be politically explosive.
Since the law was signed by Mr. Obama in March 2010, 20 million uninsured people have gained coverage, and the law has become deeply embedded in the nation's health care system, accepted with varying degrees of enthusiasm by consumers, doctors, hospitals, insurance companies and state and local governments.
Unwinding it could be as difficult for Republicans as it was for Democrats to pass it in the first place and could lead Republicans into a dangerous cul-de-sac, where the existing law is in shambles but no replacement can pass the narrowly divided Senate. Democrats would face political pressure in that case as well.
It is not sheer coincidence that at least one idea envisions putting the effective date well beyond the midterm congressional elections in 2018.
''We are not going to rip health care away from Americans,'' said Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee, which shares jurisdiction over health care. ''We will have a transition period so Congress can develop the right policies and the American people can have time to look for better health care options.''
Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said: ''I imagine this will take several years to completely make that sort of transition -- to make sure we do no harm, create a good health care system that everyone has access to, and that we repeal the parts of Obamacare that need to be repealed.''
But health policy experts suggest ''repeal and delay'' would be extremely damaging to a health care system already on edge.
''The idea that you can repeal the Affordable Care Act with a two- or three-year transition period and not create market chaos is a total fantasy,'' said Sabrina Corlette, a professor at the Health Policy Institute of Georgetown University. ''Insurers need to know the rules of the road in order to develop plans and set premiums.''
Details of the strategy are in flux, and there are disagreements among Republicans about how to proceed. In the House, the emerging plan, tightly coordinated between Mr. Ryan and Mr. Pence, is meant to give Mr. Trump's supporters the repeal of the health law that he repeatedly promised at rallies. It would also give Republicans time to try to assure consumers and the health industry that they will not instantly upend the health insurance market, and to pressure some Democrats to support a Republican alternative.
''I don't think you have to wait,'' Representative Kevin McCarthy of California, the majority leader, told reporters this week. ''I would move through and repeal and then go to work on replacing. I think once it's repealed, you will have hopefully fewer people playing politics, and everybody coming to the table to find the best policy.''
Under the plan discussed this week, Republicans said, repeal will be on a fast track. They hope to move forward in January or February with a budget blueprint using so-called reconciliation instructions, which would allow parts of the health care law to be dismembered with a simple majority vote, denying Senate Democrats the chance to filibuster. They would follow up with legislation similar to a bill vetoed in January, which would have repealed the tax penalties for people who go without insurance and the penalties for larger employers who fail to offer coverage.
That bill would also have eliminated federal insurance subsidies, ended federal spending for the expansion of Medicaid, and barred federal payments to Planned Parenthood clinics.
But in the Senate, Republicans would need support from some Democrats if they are to replace the Affordable Care Act.
The budget reconciliation rules that would allow Republicans to dismantle the Affordable Care Act have strict limits. The rules are primarily intended to protect legislation that affects spending or revenues. The health law includes insurance market standards and other policies that do not directly affect the budget, and Senate Republicans would, in many cases, need 60 votes to change such provisions.
Repealing the funding mechanisms but leaving in place the regulations risks a meltdown of the individual insurance market. Insurers could not deny coverage, but they would not get as many healthy new customers as they were expecting. Hospitals would again face many uninsured patients in their emergency rooms, without the extra Medicaid money they have been expecting.
Even a delay of two to three years could be damaging. Health policy experts said the uncertainty could destabilize markets, unnerving insurers that have already lost hundreds of millions of dollars on policies sold in insurance exchanges under the Affordable Care Act.
''Insurers would like clarity on the shape of the replacement plan to continue participating on exchanges if Obamacare is repealed,'' Ana Gupte, an analyst at Leerink Partners who follows the insurance industry, said Friday.
Republicans are hoping that Mr. Trump will be able to use his bully pulpit to lean on vulnerable Democrats up for re-election in states Mr. Trump won, such as Senators Joe Manchin III of West Virginia and Jon Tester of Montana.
''When that date came and you did nothing, if you want to play politics, I think the blame would go to people who didn't want to do anything,'' Mr. McCarthy said.
But Democrats may not be so quick to break.
''If they are looking at fixing what's there, I've been wanting to work with Republicans for years now,'' said Mr. Tester, whose state cast just 36 percent of its vote for Hillary Clinton. ''But if they are going to take away provisions like pre-existing conditions, lifetime caps, 26-year-olds, I think they are barking up the wrong tree.''
And some moderate Republicans see peril in repealing first and replacing later, favoring instead a simultaneous replacement to ensure a smooth transition.
''We are firing live rounds this time,'' Representative Charlie Dent, Republican of Pennsylvania, said. ''If we repeal under reconciliation, we have to replace it under normal processes, and does anyone believe that the Senate Democrats, with their gentle tender mercies will help us?''
Republicans said they would work with the Trump administration on replacement legislation that would draw on comprehensive plans drafted by Mr. Ryan and Representative Tom Price, the Georgia Republican picked by Mr. Trump to be his secretary of health and human services.
Any legislation is likely to include elements on which Republicans generally agree: tax credits for health insurance; new incentives for health savings accounts; subsidies for state high-risk pools, to help people who could not otherwise obtain insurance; authority for sales of insurance across state lines; and some protection for people with pre-existing conditions who have maintained continuous coverage.
Republicans said they hoped that the certainty of repeal would increase pressure on Democrats to sign on to some of these ideas.
Democratic leaders, for now, feel no such pressure. Republicans ''are going to have an awfully hard time'' if they try to repeal the health law without proposing a replacement, said Senator Chuck Schumer of New York, the next Democratic leader. ''There would be consequences for so many millions of people.''
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URL: http://www.nytimes.com/2016/12/02/us/politics/obamacare-repeal.html
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March 27, 2012 Tuesday
Late Edition - Final
Getting to the Merits
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 465 words
Before ruling on whether Congress has power to require Americans to obtain health insurance, the Supreme Court must decide whether it is barred from taking up that question by the federal Anti-Injunction Act, which prohibits courts from hearing lawsuits that seek to block a tax before the tax is actually paid.
During an hour and a half of oral arguments on Monday, the justices showed their interest in addressing the merits of the case and their skepticism that the Anti-Injunction Act posed an insurmountable hurdle to doing so. That instinct seems right.
The Affordable Care Act will alter the national health care markets to help all Americans, and putting off judgment on the spurious constitutional objections from the law's opponents would delay putting those arguments to rest -- and likely make it more difficult for the government to provide health coverage to millions of Americans who do not have it now.
The justices also seemed properly concerned about finding a way to rule narrowly on the Anti-Injunction Act issue if they dismiss it, to avoid creating a precedent with unintended consequences, like allowing a flood of unwanted court challenges to government assessments.
In a friend-of-the-court brief filed at the request of the court, Robert Long Jr., an independent advocate, argued that the Supreme Court should dismiss the case ''for lack of jurisdiction'' because the penalty, which is imposed on people who do not obtain insurance, would not be collected until 2015. Solicitor General Donald Verrilli Jr. proposed a sensible way for the court to address the merits of the health care case, without eviscerating the anti-injunction law in other types of tax cases.
The Obama administration, while agreeing with Mr. Long that the anti-injunction law bars federal courts from hearing certain tax cases before their time, concludes that the penalty for failure to obtain insurance under the Affordable Care Act is not a tax as defined by the statute.
The administration's position is subtle, but legally sound. As Mr. Verrilli explained, in interpreting a statute like the Anti-Injunction Act, ''the precise choice of words'' matters. If the Affordable Care Act had called the penalty a tax, the Anti-Injunction Act would likely have knocked out this case. Justice Stephen Breyer further pointed out in court, ''Congress has nowhere used the word 'tax.' What it says is penalty. Moreover, this is not in the Internal Revenue Code 'but for purposes of collection.' And so why is this a tax?''
This issue is technical, and it is imperative that the justices interpret the anti-injunction law so that the ruling in this case is consistent with what makes sense in conventional tax cases. A careful analysis of this law will allow the court to get to the case's central questions.
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(You're the Boss)
July 3, 2013 Wednesday
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 815 words
HIGHLIGHT: The delay will give businesses time to press their cases to Congress for changes in provisions of the health care overhaul.
It seems that almost nobody was ready for the employer mandate in the Affordable Care Act to take effect - not government regulators, not the managers of health insurance exchanges, and not the employers - and that a year's delay could buy time for the government to write regulations and for companies to figure out how to comply with them. But many businesses hope to get something else from the one-year delay: an opportunity to rewrite other aspects of the mandate that they find difficult.
In particular, businesses are unhappy that the law defines a full-time employee to whom a business must offer affordable health insurance as someone who works at least 30 hours a week. "We've argued that the 40-hour workweek is where most people think the full-time work level should be," said Neil Trautwein, employee benefits policy counsel at the National Retail Federation, a trade association. "It goes to the compliance burden on employers, and employees, and the balance of full- and part-time employees. What happens to people who prefer to work part time, and find their hours reduced to stay under the 30-hour limit?"
A 30-hour threshold, he added, will create "a new class of 29-ers," workers with schedules set just below the threshold.
Mr. Trautwine and others have portrayed the 30-hour threshold in the Affordable Care Act as a source of confusion and complexity, since the Fair Labor Standards Act sets the full-time workweek at 40 hours (and establishes rules for overtime pay based on that). The lower definition will require many companies to offer insurance to more employees, which would make providing benefits much more expensive - hence the schedule juggling that Mr. Trautwein foresees.
Tracking who is entitled to benefits might also become more challenging for some companies. "It's all about proving who's a full-time employee and who's not," said Alan Cohen, chief strategy officer for Liazon, which operates a private benefits exchange for employers. "A lot of these employers don't track hours, so they don't even know if they're full time." One client, a home health care provider, for example, pays its nurses per visit, not per hour. "This company not only has to provide health insurance, but it also has to buy new systems to track hours," he said.
"Businesses are looking for something that's easier to administer and doesn't require them to give coverage to people only working for you for two or three days," said J.D. Piro, a senior vice president at the benefits consulting company Aon Hewitt in charge of the health law group. The 30-hour requirement, he said, ran contrary to the spirit of the health law overhaul.
"The idea behind the Affordable Care Act is to keep employers in the game and allow them to provide insurance without making major changes either way," he said, "not forcing them to expand coverage or forcing them to drop coverage for employees."
Mr. Trautwein, of the retail group, said that the delay would give his group and others time to press their cases to Congress, where, he said, legislation revising the 30-hour rule has bipartisan support. Once the mandate goes into effect, he said, it would be harder to change it. "We really need relief before implementation," he said. His group would also like to see the threshold for which companies must abide by the mandate increased from 50 employees.
Mr. Piro, however, said he doubted that such legislation would go very far. "I don't think there are going to be any changes to this act with the current split in Congress," he said.
A veteran health policy consultant in Washington, who insisted on anonymity, explained the situation this way: "Opponents of the legislation don't want to fix this issue, they want to use it as fodder to repeal the whole law. They have no interest in moderating or amending the law, because that implicitly affirms that the law is worth amending."
Meanwhile, the law's supporters won't amend the law, the consultant said, because they fear opponents would use the bill to derail the whole law. "We're really at a point where we implement the law as it was enacted," he said.
Apparently, lobbyists and benefit advisers were genuinely surprised at the administration's decision to delay the mandate, but in the current political environment, this consultant said, they should not have been.
"If you understand both the political dynamic and the fact that this executive decision does not undermine the foundation or infrastructure of the law but still allows for being responsive to employer concerns," he said, "it's almost a no-brainer that this decision was made."
Bakery Owner Talks About Coping With Health Insurance Changes
Should a Bakery With More Than 50 Employees Offer Health Insurance?
The Challenges of Raising Prices and Competing With Online Retailers
This Week in Small Business: Gordon Ramsay Calling!
Paid Sick Leave Has Some Business Owners Feeling Ill
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February 27, 2014 Thursday
Study Indicates That Bill Redefining Full-Time Employment Would Have Costs
SECTION: BUSINESS; smallbusiness
LENGTH: 655 words
HIGHLIGHT: The Save American Workers Act would move the definition of full-time employment to 40 hours and require businesses to provide health insurance to fewer workers.
A few weeks ago, we reported on the sudden interest among House Republicans in legislation to rewrite the employer mandate in the Affordable Care Act.
The law requires companies with 50 or more employees to pay a penalty if they do not offer health insurance to every full-time worker. What the House Republicans would like to change is the definition of full time, which the law sets at 30 hours. The bill the Republicans are backing, called the Save American Workers Act, would move the definition to 40 hours and require businesses to insure fewer workers.
Opponents of the bill argue that not only would employees who have been working 30 to 40 hours lose coverage but that businesses would cut the hours of their 40-hour-a-week employees to avoid having to offer those workers insurance as well. In addition, opponents say the bill would increase the deficit.
The Ways and Means Committee held a hearing on the matter in late January; a week later the bill passed out of the committee, headed to the House floor.
Now we know what that legislation might cost, should it somehow defy a Democratic Senate and president to become law. On Tuesday, as Talking Points Memo has reported, the nonpartisan Congressional Budget Office and the Joint Committee on Taxation released an estimate of the bill's effects. The report concludes that the bill would cause one million workers to lose health insurance from their employers.
Of those million, however, at least half, and perhaps all of them, could be expected to find insurance elsewhere, either on the individual insurance exchanges set up under the Affordable Care Act, through Medicaid, or through the Children's Health Insurance Program.
Considering that almost 160 million people receive health insurance through the workplace, one million represents a very small fraction that would be affected by the proposed law - just six-tenths of a percent of the total population with an employer's health coverage. If the threshold were changed, the report said, "most of the affected employers would continue to offer coverage because most employers construct compensation packages to attract the best available workers at the lowest possible cost," and employees still prefer to get insurance from the workplace than to find it on their own.
Indeed, the small-business owner who testified in favor of the Save American Workers Act at last month's hearing, a hotelier from Maine, later acknowledged that even if the law were changed, he would not change his own policy of offering health insurance to employees who work more than 30 hours a week.
Supporters of raising the threshold argue that under the current rule, employers will reduce employees' workloads to below 30 hours to avoid offering insurance. At last month's hearing, a researcher at the conservative Hoover Institution presented a study claiming that 2.6 million people are vulnerable to reduced hours (and losing the insurance) under the 30-hour threshold, much higher than the congressional office's estimate for a 40-hour threshold. That puts the Hoover study at odds with the congressional researchers, who found that more people would face reduced hours and lost coverage if the bill passes, because many more people work at or above a 40-hour threshold than a 30-hour threshold.
The Save American Workers Act would add $74 billion to the deficit over 10 years, according to the report. That is because many of the people who would lose their employer health coverage if the threshold were raised would then get subsidized coverage elsewhere and because the penalty employers pay under the mandate would be reduced.
A Hotelier Corrects His Testimony on the Impact of the Affordable Care Act
Small Businesses Showing Little Interest in State SHOP Exchanges
What I Needed to Understand About Health Insurance
A Small Business Starts to Navigate the Affordable Care Act
Why Labeling Health Plans Gold, Silver or Bronze Doesn't Help
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(Taking Note)
January 28, 2015 Wednesday
Facts & Figures: Another 'Obamacare' Repeal Vote
BYLINE: THE EDITORS
SECTION: OPINION
LENGTH: 102 words
HIGHLIGHT: House Republicans want to give their newest members a chance to voice their opposition to the Affordable Care Act.
House Republicans want to give their newest members a chance to voice their official opposition to the Affordable Care Act, with yet another vote to repeal.
Via PBS Newshour
House Republicans, leadership aides confirm, will move forward with a bill on full repeal of the health care law, something Republicans have done half a dozen times now. (They have voted more than 50 times on measures relating to changing the law, including six times for full repeal). So why are Republicans doing this again? Frankly, because newly elected freshmen members haven't voted for it before, and they want the opportunity to do so.
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October 2, 2013 Wednesday
Today in Small Business: When Your Biggest Client Disappears
BYLINE: GENE MARKS
SECTION: BUSINESS; smallbusiness
LENGTH: 580 words
HIGHLIGHT: Four small-business myths about the Affordable Care Act, ADP reports fewer new jobs than expected and one of the most successful marketing campaigns in history.
What's affecting me, my clients and other small-business owners today.
The Shutdown, Day 1
A small federal contractor explains what it's like to have her biggest client disappear.
Many black-owned small businesses are feeling the sting.
This is what we listened to and watched during the last shutdown.
Here's a round-up of shutdown coverage.
Health Care
The small-business exchange encounters problems on its opening day.
A small-business owner sues the Obama administration over the employer mandate delay.
Paul Krugman says the glitches are good glitches.
J.D. Harrison corrects four myths about the Affordable Care Act and small businesses.
The Economy
ADP reports that companies have added fewer jobs than expected. Jon C. Ogg reports that small-business hiring is so low it is "almost invisible."
American Airlines plans to hire 1,500 pilots over the next five years.
Macy's will hire 83,000 seasonal workers and Amazon 70,000.
Economic activity in the manufacturing sector expanded in September for the fourth consecutive month.
Finance
Christine Lagorio-Chafkin reports that the Jobs Act could make it harder for your friends and family to finance your business: "By opening up solicitation, the government also limited who can fund your business for equity in certain cases. Once you start talking openly about your fundraising, you relinquish the right to include your very interested but not very wealthy Uncle Pennybags in your funding round. 'The letter of the law is that if you are generally soliciting your round, you have to go to accredited investors only,' says Chance Barnett, a serial entrepreneur, start-up adviser and C.E.O. of Crowdfunder.com, a platform for equity-based investment.'"
Chase plans to award $3 million in grants to small businesses.
Marketing
Big businesses are seeking marketing wins using contests aimed at small businesses.
George Deglin says the "Chipotle Scarecrow will, without a doubt, go down as one of the most successful marketing campaigns in history. The higher cost of building mobile games has for a long time discouraged brands from exploring the mobile market. However, the success of Chipotle's Scarecrow has shown advertisers that despite their increased cost, mobile advergames are a huge untapped opportunity."
Ideas
KFC releases take-out containers made to fit your car's cup holder.
A young owner describes what it's like to be in the apiary business.
The world's craziest toothbrush cleans your teeth in six seconds and can be 3-D-printed.
Around the Country
Chicago's oldest pet shop closes after refusing to sell dogs from puppy mills.
The Simpsons will soon be killing off a character.
Around the World
G. Scott Thomas reports that America's top 30 markets wield more economic clout than China.
October is small-business month in Okanagan, British Columbia
A Saudi cleric warns that driving could damage women's ovaries.
Technology
Here are seven steps to build a billion-dollar app.
This is how to hack your own bank account using information on the Internet.
Apple is sitting on an extraordinary pile of cash.
Gene Marks owns the Marks Group, a Bala Cynwyd, Pa., consulting firm that helps clients with customer relationship management. You can follow him on Twitter.
What Does the Affordable Care Act Mean for Your Business?
A Health Insurance Offer for the Busy Start-Up
Business Owners Say They Have Yet to Figure Out Health Care
Employer Mandate, Delayed by Paperwork (and Efforts to Reduce It)
It's the Affordable Care Act. But What Is Affordable?
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November 17, 2014 Monday
The International New York Times
In Congress, Obama's Health Act Is Still a Target
BYLINE: By ALBERT R. HUNT | BLOOMBERG VIEW
SECTION: Section ; Column 0; Foreign Desk; LETTER FROM WASHINGTON; Pg.
LENGTH: 678 words
WASHINGTON -- As President Obama and congressional Republicans profess to search for common ground, both sides are preparing to lob grenades: the president with an executive action on immigration, the new Congress by making the repeal of the Affordable Care Act one of its first initiatives.
The furor over an immigration action, which some Republicans charge would be an impeachable offense, is overdone. Whatever Mr. Obama does could be overturned by Congress or rescinded by the next president; that's the nature of executive actions.
And a move to repeal the Affordable Care Act is merely a sop to the Republican Party's right-wing base. It isn't likely to get through the Senate, and it certainly wouldn't overcome a presidential veto.
But there will be changes to the health care law in the Republican-controlled Congress. The nature and scope of those adjustments will have important implications for health care and politics.
There is some low-hanging fruit for Republicans, starting with the small tax on medical-device makers that helps fund the Affordable Care Act. Most studies indicate that the levy, which will raise $29 billion over 10 years, creates little hardship for the industry.
Nonetheless, device makers have waged an effective lobbying campaign against the tax. And its repeal is now supported by liberal Democrats such as Amy Klobuchar and Al Franken of Minnesota, as well as Elizabeth Warren and Edward Markey of Massachusetts, whose states are home to manufacturers. The repeal effort is likely to sail through Congress and probably wouldn't face a presidential veto. The only question is whether the fiscal watchdogs in Congress would replace it with a comparable revenue source.
There is also a Republican proposal to change the definition of full-time work. The plan would allow employers to avoid providing health care coverage to workers who put in less than 40 hours a week, up from 30 hours now. A compromise is likely. Given that a fairly large number of workers might be reclassified as part time, it might make more sense to replace the entire employer mandate. But that's politically difficult because it would be virtually impossible to find a way to take care of those who would lose their coverage.
But any move to alter the individual mandate would face a certain White House veto. Ironically, the mandate was a Republican idea: It was the cornerstone of former Gov. Mitt Romney's health care plan in Massachusetts.
''We have known for 70 or 80 years that voluntary health care insurance is a failure; it has to be mandatory,'' said Ezekiel Emanuel, a former top Obama health care adviser who is now a vice provost at the University of Pennsylvania.
There are two other less noticed provisions of the huge bill that have been targeted by big drug makers, hospitals, the American Medical Association and congressional Republicans. One is the independent payment advisory board that would recommend cuts to the program (subject to congressional approval) if the rise in Medicare spending becomes excessive. The other provision is the Patient-Centered Outcomes Research Institute, which analyzes the effectiveness of medical treatments.
Possibly the biggest threat to Mr. Obama would be if the Supreme Court threw out the subsidies for uninsured people on federal exchanges who don't qualify for Medicaid.
There is danger for Mr. Obama in how all this plays out. Some changes could severely undermine the president's signature domestic policy achievement.
That would also carry risk for Republicans, however. The public tends to express a negative view of the Affordable Care Act, but individual provisions of the law are gaining support. In a decidedly Republican midterm electorate this month, voters nationally and in battleground states were divided between those who said the health care act went too far and those who said it was just right or didn't go far enough. If beneficiaries are adversely affected and a conservative majority on the Supreme Court makes what critics will call a partisan decision, there could be a strong backlash.
URL: http://www.nytimes.com/2014/11/17/us/politics/in-congress-obamas-health-care-act-is-still-a-target.html
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July 6, 2016 Wednesday
Late Edition - Final
Court Strikes Down Obama Health Care Rule Backing Insurance Standards
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 832 words
WASHINGTON -- A federal appeals court has ruled that consumers must be allowed to buy certain types of health insurance that do not meet the stringent standards of the Affordable Care Act, deciding that the administration had gone beyond the terms of federal law.
The court struck down a rule issued by the Obama administration that barred the sale of such insurance as a separate stand-alone product.
''Disagreeing with Congress's expressly codified policy choices isn't a luxury administrative agencies enjoy,'' the United States Court of Appeals for the District of Columbia Circuit said on Friday in a decision that criticized ''administrative overreach'' by the Department of Health and Human Services.
At issue is a type of insurance that pays consumers a fixed dollar amount, such as $500 a day for hospital care or $50 for a doctor's visit, regardless of how much is actually owed to the provider.
Such ''fixed indemnity'' insurance is normally less comprehensive and less expensive than the ''minimum essential coverage'' required by the Affordable Care Act. Under the rule, issued by the Obama administration in 2014, fixed indemnity policies could be sold only to people who already have the more comprehensive coverage that meets detailed federal standards.
State officials and insurers estimate that as many as four million people might have fixed indemnity policies without major medical coverage.
The Obama administration gave several reasons for cracking down on fixed indemnity insurance. It is ''an inadequate substitute for major medical coverage'' because ''it does not provide protection against major medical expenses,'' the administration said. Moreover, it said, consumers may be confused and may buy fixed indemnity insurance in ''the mistaken belief that it provides comprehensive coverage'' -- a concern also voiced by consumer groups.
In adopting the final rule in 2014, the Obama administration said that allowing people to buy free-standing fixed indemnity insurance would undermine the goal of ''maximizing the number of individuals who have comprehensive, major medical coverage.''
Since 1996, fixed indemnity insurance has generally been exempt from federal insurance standards, and the Affordable Care Act did not change that, nor did Congress ''give even the slightest indication'' that it meant to alter the exemption, the appeals court said.
But, the court said, the administration ''effectively eliminated stand-alone fixed indemnity plans altogether,'' by tacking ''additional criteria'' onto the 1996 law.
The ruling in the case, Central United Life Insurance v. Burwell, was issued by a panel composed of Judges Janice Rogers Brown, Patricia A. Millett and Douglas H. Ginsburg.
Fixed indemnity insurance differs from major medical coverage in many ways. It does not have to provide the ''essential health benefits'' required by the Affordable Care Act, nor does it have to pay any specific percentage of medical costs. Some fixed indemnity policies provide coverage only for specified diseases, like cancer. In general, consumers have fewer protections.
Under the rule issued by the Obama administration, fixed indemnity insurance would be allowed only as a supplement to major medical coverage that complied with the 2010 health care law. People buying the more limited coverage would have to attest, in their applications, that they already had ''minimum essential coverage.''
The plaintiffs in the case, who sell fixed indemnity insurance, said the federal rule would essentially destroy the market for such products.
''Even after the Affordable Care Act, lower-income consumers may not be able to afford major medical coverage,'' said Quin M. Sorenson, a lawyer at Sidley Austin who represented the plaintiffs. In states that have not expanded Medicaid eligibility, he said, three million people fall into a coverage gap: They make too much to qualify for Medicaid, but not enough to qualify for subsidies in the public insurance marketplace, and they cannot afford major medical coverage on their own.
For some of them, he said, fixed indemnity insurance plans may be a valuable option.
Under the Affordable Care Act, people who go without major medical coverage may be subject to tax penalties. In a friend-of-the-court brief, Wisconsin and 10 other states said that some consumers had found they could save money by buying fixed indemnity insurance and paying the tax penalty.
''Fixed indemnity insurance is a rational choice for these individuals because it provides meaningful access to the health care system,'' the states' brief said.
The appeals court upheld an earlier decision by Judge Royce C. Lamberth of Federal District Court, who said the Obama administration's rule ''has no basis in the statutory text it purports to interpret and plainly exceeds the scope of the statute.''
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URL: http://www.nytimes.com/2016/07/06/us/politics/court-strikes-down-obama-health-care-rule-on-insurance-standards.html
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December 7, 2016 Wednesday 00:00 EST
Protecting Reproductive Rights Under Donald Trump;
What's at Stake
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 586 words
HIGHLIGHT: The Trump administration could put reproductive health care out of reach for millions, but states can fight back.
During his presidential campaign, Donald Trump sent mixed messages about his position on reproductive rights. Whatever his personal opinion may be, his appointees and their actions could put reproductive health care out of reach for millions of women, especially those living in poverty.
Mr. Trump has promised to appoint a Supreme Court justice who opposes Roe v. Wade, but overturning that decision would be a long process, probably requiring two new justices. Even without that change, there are many potent ways to restrict reproductive rights - including not defending them against legal attack.
The Obama administration has waged long battles against such attacks. The Justice Department supported abortion providers in their successful challenge against unconstitutional abortion restrictions in the 2016 Supreme Court case Whole Woman's Health v. Hellerstedt. It defended the provision of the Affordable Care Act that requires insurers to cover birth control without a co-pay. It enforces the Freedom of Access to Clinic Entrances Act, which protects abortion providers and patients from violence and intimidation. After several states attempted to bar Planned Parenthood from receiving Medicaid reimbursements, the administration warnedthem that such measures could violate federal law. And the Department of Health and Human Services has proposed a rule that would bar states from cutting off federal family-planning funds to any provider for ideological reasons.
If Jeff Sessions, who opposes abortion, is confirmedas attorney general, the Justice Department is unlikely to defend reproductive rights. While the fate of the Affordable Care Act rests with Congress, the Justice Department could stop fighting lawsuits challenging the contraceptive coverage requirement. Under Mr. Sessions, it could stop enforcing the FACE Act, leaving abortion providers with little recourse if anti-abortion extremists threaten patients or doctors or obstruct clinic entrances.
Vice President-elect Mike Pence, when he was a congressman, tried to prevent any federal money from going to Planned Parenthood. The Trump administration, under Mr. Pence's guidance, could stop enforcing the Medicaid reimbursement law that prohibits states from discriminating against Planned Parenthood. And Tom Price, Mr. Trump's pick for secretary of health and human services and an unwavering opponent of the Affordable Care Act, could as head of that department rescind the contraceptive coverage requirement. Such federal actions may well embolden some Republican-controlled state governments to further restrict reproductive rights.
While the picture is bleak, there are ways states can ameliorate the harm. State legislatures can require that insurers cover birth control without a co-pay; four states already have such a requirement. States can protect family planning by increasing their support for these programs. The Montana Legislature did so last year with a bipartisan bill that moved federal family-planning funds into an account controlled by the state health department, making it harder for future legislators to cut them. And states can pass their own clinic safety laws to protect women and abortion providers.
Recent years have seen real progress in reproductive health, from lower rates of teenage pregnancy to more effective contraceptive use. Those are gains for Americans to build upon, not undo.
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June 22, 2012 Friday
Awaiting the Supreme Court's Health Care Ruling
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1100 words
HIGHLIGHT: The lack of a clear legal consensus on the underlying issues of the health care act may pave the way for the Supreme Court to rule based on ideology, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
Anticipation has reached a fever pitch this week as the nation awaits the Supreme Court's decision on the fate of the Affordable Care Act of 2010.
The core question before the court is whether the Commerce Clause in Article 1, Section 8, Clause 3 of the Constitution grants the federal government the authority to mandate individual Americans to purchase specified, minimally adequate health insurance coverage from private health insurers.
For an economist, whose profession is routinely mocked with the adage "two economists, three opinions," the spectacle has been heartwarming.
Evidently American legal theory is in even greater disarray than is economic theory. In this instance, the best legal minds in the nation cannot agree on what the Commerce Clause means. So we look to nine justices to tell us what they think the clause might mean. With legal theory in such disarray, ideological predilection among the justices may triumph.
I recently posted a commentary on the options before the Supreme Court. Expanding upon that post a bit, I would describe the options before the Court thusly:
1. The Affordable Care Act is upheld as constitutional in all of its provisions.
2. Only the individual mandate is struck down, and it is deemed severable from the rest of the act.
3. Title 1 (Insurance Reform) of the act is struck down, but the rest of the act is upheld.
4. Both Titles 1 and 2 (Public Programs, including the expansion of Medicaid) are struck down, but the rest of the act is upheld.
5. The entire Affordable Care Act is struck down, on the grounds that the clause covering the individual mandate, deemed by the justices to be not authorized by the Commerce Clause, is deemed not severable from the rest of the bill.
Before the oral arguments at the court in March, the first option was widely given a good chance, especially among lawyers. The justices' many hostile questions on the mandate during oral arguments gave many observers second thoughts.
If I had to bet, I would put my marker on the second option, the striking down of the individual mandate only. The majority of the justices may sincerely believe that the Commerce Clause does not authorize the mandate. In addition, some may not be averse to giving the president a little slap in the face. In any event, striking the mandate would not do much damage to the rest of the bill.
That is because the penalties for disobeying the mandate now written into the statute are relatively low, which invites evasion by anyone whose premiums payable would exceed the penalty. Furthermore, it is easy to think of legislative fixes that could substitute for the mandate and, indeed, might even have more bite.
The administration has argued that three important provisions in Title 1 of the act - community rating, guaranteed issue and guaranteed renewability - depend on the individual mandate for sound actuarial functioning of the act.
To be "actuarially correct," so to speak, the court might therefore strike these three provisions of Title 1 as well, along with the individual mandate.
The administration's reasoning has encouraged a number of the act's opponents to submit to the court an amici curiae brief recommending that the entire Title 1 be struck down, along with the mandate.
Title 1 covers all the provisions for the reforms of the individual and small group market for health insurance, including the minimum medical loss ratios to be attained by insurers and the subsidies toward insurance premiums for low-income individuals not qualifying for Medicaid.
The amici's argument is that without the individual mandate Congress would not have enacted the rest of Title 1. In other words, the amici ask the court to divine what Congress might or might not have done. It would require the justices to assume, inter alia, that Congress always acts rationally - a very tall assumption, indeed. I would be surprised if the justices were persuaded by the specious argument of these amici.
Striking Title 1 would be a blow not only to millions of uninsured Americans whose health insurance coverage was to be subsidized by the federal government. It would also be a blow to the providers of health care who would lose a sizable net new revenue flow and would continue to be besieged by the millions of uninsured, should they fall ill.
For the health insurance industry it would be a mixed blessing or blow. On the one hand, it would free the industry from a good number of new regulations. On the other, it would take away millions of potential new customers and, moreover, expose the industry to the highly negative publicity over medical underwriting and premiums based on the individual's health status.
The justices' questioning during oral arguments suggests to me that they are not likely to strike down Title 2 of the act - Public Programs, including Medicaid expansion - should they strike down Title 1. The justices did not seem convinced that a deal offered the states by the federal government could be so generous as to be coercive and, thus, unconstitutional.
Finally, the justices could defend repeal of the entire Affordable Care Act by the absence of a severability clause in the act, although it strikes me as even less likely than striking just Titles 1 and 2. That would not be a slap in the president's face, but a hefty whack with a two-by-four. Would the chief justice want this as part of his legacy?
Furthermore, the rest of the bill contains numerous provisions for enhancing the quality of American health care and providing greater transparency on both quality and prices. In less partisan times, both parties have favored most of these measures.
So, of course, have they favored the individual mandate in years past. It is fascinating, for example, to behold the list of co-sponsors of Senate bill S.1770 introduced in 1993 by the late Senator John H. Chafee, Republican of Rhode Island. That bill included the individual mandate. Among the co-sponsors was Senator Orrin Hatch, Republican of Utah, now a vocal opponent of the mandate.
It would be instructive for the historical record to learn what epiphany caused this distinguished legislator, long a member and a former chairman of the Senate Judiciary Committee, to make a 180-degree turn on the mandate.
Health Care: Solidarity vs. Rugged Individualism
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
From Physician Glut to Physician Shortage
Reaction to the Final Hearing on the Health Law
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(You're the Boss)
September 15, 2012 Saturday
Small Business Health Insurance: Costs Still Going Up
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 708 words
HIGHLIGHT: For many, the real impact of the Affordable Care Act, should it survive, is still two years away.
The news for small businesses - not particularly surprising and not particularly good - in the Kaiser Family Foundation's latest study of employer-sponsored health insurance is that the trend lines are unchanged. Costs continue to go up, and the number of companies offering insurance does not.
While across all employers, premiums for family coverage grew at the modest rate of 4 percent over the last year, small businesses faced an increase double that - the biggest annual increase in family plans since 2004. For individual coverage, small-company premiums increased 5 percent, which was also more than the increase in the broader market.
Some small-business owners have reported paying a larger share of employee insurance premiums as those costs have gone up, but that has barely registered on the Kaiser survey, which is conducted every year. This year, small companies (with fewer than 200 employees) paid 84 percent of premiums for individual coverage - more than large companies typically pay - and 35 percent for family coverage, a smaller share than at big companies.
But small employers are continuing to try to keep cost down in other ways. For example, they are still migrating to the cheapest plans. These are the high-deductible plans, often coupled with a savings arrangement, that are popular among conservative economists and policymakers. Increasingly, they are popular among small businesses, too. Since 2006, and especially since 2010, they have grown to cover nearly a quarter of all small-business employees, eclipsing every other kind of plan except so-called "preferred provider" coverage. (High-deductible plans are even more popular at large companies.) Deductibles are in fact rising for most employees - nearly half of covered employees at small companies in individual plans have a deductible above $1,000, and just over a quarter pay more than $2,000.
Despite all this, slightly more small companies - 61 percent - are offering health insurance this year, but that figure has been fairly stable since 2004. The small-business health care tax credit in the Affordable Care Act was meant to bolster that figure by inducing companies with the smallest and poorest-paid workforces to buy health insurance. (The credit is fully available to businesses with 10 or fewer employees with average wages below $25,000.) But it appears not to have moved the needle much. Health insurance coverage from companies with fewer than 10 employees suddenly spiked in 2010, for reasons that Kaiser couldn't explain, but fell back in 2011 and holds steady in the latest survey. A similar bounce occurred among companies (of any size) with a preponderance of low-wage workers, but the subsequent decline was sharper - just 29 percent of those companies offer insurance now, a third fewer than did in 2008 and 2009.
Indeed, it may prove difficult to associate many of the findings in the Kaiser study with the Affordable Care Act. The changes made by the law that have already taken effect mostly took effect in 2010. In fact, Kaiser's 2011 survey reported average premium increases between 8 and 9 percent over the 2010 coverage, the largest annual changes since 2005, although that study took care not to identify causes for them.
The big changes will come in 2014 (if the law isn't repealed first). And there is one thing the new study tells us about those changes: more small businesses will be affected by them. In 2011, 72 percent of small companies offering insurance indicated that they had at least one health plan that was deemed "grandfathered" - that is, an existing plan that would not have to meet the law's new standards. (Remember the promise the law's advocates made that "if you like your plan, you can keep it"? This is what they were talking about.) This year, that share has fallen to 58 percent, and the proportion of small-company employees enrolled in a grandfathered plan has dropped, too, from 63 percent to 54 percent.
A Small Restaurant Gets a Big Increase in Health Premiums - and Misses the Tax Credit
Business Owners Try to Make Sense of Health Care
For Small Business, Bad News on Health Care Costs Isn't as Bad
Doing the Math on Employer Health Insurance
The Affordable Care Act Rebate Checks Are in the Mail: Now What?
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November 14, 2013 Thursday
Late Edition - Final
With Enrollment Slow, Some Democrats Back Change in Health Law: A Push to Restore Policies Being Canceled
BYLINE: By ASHLEY PARKER and MICHAEL D. SHEAR; Jonathan Weisman and Jeremy W. Peters contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1163 words
WASHINGTON -- Anxious congressional Democrats are threatening to abandon President Obama on a central element of his signature health care law, voicing increasing support for proposals that would allow Americans who are losing their health insurance coverage because of the Affordable Care Act to retain it.
The dissent comes as the Obama administration released enrollment figures on Wednesday that fell far short of expectations, and as House Republicans continued their sharp criticism of administration officials at congressional hearings examining the performance of the health care website and possible security risks of the online insurance exchanges.
In addition, a vote is scheduled Friday in the Republican-controlled House on a bill that would allow Americans to keep their existing health coverage through 2014 without penalties. The measure, drafted by Representative Fred Upton, the Michigan Republican who is the chairman of the Energy and Commerce Committee, is opposed by the White House, which argues that it would severely undermine the Affordable Care Act by allowing insurance companies to continue to sell health coverage that does not meet the higher standard of Mr. Obama's health care law.
But a growing number of House Democrats, reflecting a strong political backlash to the rollout of the law, are warning the White House that they may support the measure if the administration does not provide a strong alternative argument. The approaching House vote is shaping up as an important test for both the health measure and the unity that Democratic leaders have so far been able to maintain around it despite a fierce Republican attack.
In a closed-door meeting Wednesday of House Democrats and White House officials, tensions flared as several lawmakers upbraided the administration, saying that the president had put Democrats in a tough political position by wrongly promising consumers that they could keep their existing health care plans. In fact, hundreds of thousands of Americans have received cancellation notices from their insurers because their health care coverage does not meet the minimum standards dictated by the new law.
''I'm frustrated in how it rolled out, and I let them know in no uncertain terms,'' said Representative Mike Doyle, Democrat of Pennsylvania. ''The point I was making in caucus to the administration is don't give us this techno-babble that you're going to do some administrative fix down the road. There's a bill being put on the floor on Friday.''
The overall message of the meeting, said several attendees, was that the White House and the House Democratic leadership have until Friday to come up with a satisfactory alternative, or House Democrats may be forced to support Mr. Upton's bill, which already has two Democratic co-sponsors: Representatives John Barrow of Georgia and Mike McIntyre of North Carolina, who represent more conservative districts.
''I think the Upton bill is terrible, but we need something else to vote for in order to keep our word to the American people,'' Mr. Doyle added. ''We told people in those plans that they were grandfathered in, and if they wanted to stay in them, they could, and we need to honor that.''
A similar proposal, which would allow people to keep their current health insurance permanently, is also drawing support in the Senate under an effort led by Senator Mary L. Landrieu, Democrat of Louisiana. Ms. Landrieu said she remained committed to her bill, despite White House expressions of reluctance to embrace a legislative fix. Still, the White House spokesman, Jay Carney, said Wednesday that the Landrieu proposal ''shares a similar goal to what the president has asked his team to explore.''
''We are happy to work with her and any member of Congress who has ideas on how to make the Affordable Care Act better,'' he said.
Ms. Landrieu drew a distinction between her plan -- which she said would maintain the key provisions of the Affordable Care Act -- and those offered by Republicans that would dismantle the law, like the one introduced by Mr. Upton.
''That bill guts the Affordable Care Act. It does not fix it,'' she said. ''It guts it, and I don't support it and would urge the Democrats in the House not to support it. My bill is not meant to undermine the Affordable Care Act; it's meant to strengthen it.''
She expressed confidence that more Democrats would sign on to her plan, which is designed to encourage people to move eventually to better insurance on the federal exchange. ''Every day I think we'll pick up co-sponsors,'' she said, pointing to Senator Dianne Feinstein of California, who said Tuesday that she was on board. On Wednesday, Senator Jeff Merkley, Democrat of Oregon, also signed on to her plan as a co-sponsor.
Senator Harry Reid of Nevada, the majority leader, said Wednesday that he had had ''quite a long conversation'' with the president on Tuesday evening about the health care law, as well as other issues, and would be holding a special Democratic caucus meeting on Thursday with White House officials to discuss the next steps.
Administration officials conceded that the bungled health care rollout had produced a turbulent political situation in Washington. But they said they were confident that fixing the website, HealthCare.gov, would help Democrats in next year's elections.
Mr. Carney said the president's top aides were working to come up with an administrative fix to the problem of the cancellation of health insurance plans. But he declined to say when that would be announced or whether it would come before Democrats are asked to vote on Friday.
''Sooner rather than later,'' Mr. Carney said several times.
White House officials said they recognized the need for Democrats to vent their frustration about the health care problems. Mr. Carney said that the dissatisfaction felt by Democrats on Capitol Hill ''is similar to the frustration that the president feels.''
But they continued to oppose Mr. Upton's bill, saying it would create more problems than it would solve.
''Intentionally or not, the bill would not just address the problem,'' Mr. Carney said, adding that it would ''essentially allow insurers to sell new plans that are substandard and potentially undermine the central promise of the Affordable Care Act.''
Insurance companies, already deeply worried about the low enrollment in the plans they are offering on the insurance exchanges, say congressional proposals to force them to allow canceled policies to be reissued could be disastrous. Robert Zirkelbach, a spokesman for America's Health Insurance Plans, the industry's lobby, said insurers ''have significant concerns on how it would work operationally.''
But with no alternative proposal from the White House as of Wednesday, Democrats were increasingly critical.
''This has been a complete embarrassment,'' Representative Patrick Murphy, Democrat of Florida, said. ''It doesn't matter what party you are. The focus needs to be how do we get this right.''
URL: http://www.nytimes.com/2013/11/14/us/politics/democrats-threaten-to-abandon-obama-on-health-law-provision.html
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GRAPHIC: PHOTO: Representatives Elijah E. Cummings, left, and Darrell Issa traded barbs on Wednesday at an oversight committee hearing. (PHOTOGRAPH BY GABRIELLA DEMCZUK/THE NEW YORK TIMES)
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(You're the Boss)
April 11, 2014 Friday
What Limiting the Employer Mandate Would Mean for Small Businesses
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 569 words
HIGHLIGHT: One interesting aspect of the bill that passed the House is that both its advocates and opponents seem to overstate its potential effects.
The Save American Workers Act of 2014, which seeks to limit the reach of the Affordable Care Act's employer mandate, has led a charmed life, for a bill. Most of its fellow legislation languishes in committee and never gets a public airing. But the Save American Workers Act was in and out of the House in a matter of months.
The bill would change the mandate's definition of a full-time employee who must be offered health insurance from someone who works 30 hours a week to someone who works 40 hour a week. At first, it's future didn't look promising: It sat in the Ways and Means Committee for seven months after Indiana Republican Todd Young introduced it. But in January, it caught the attention of Republican leaders. They held a hearing on how the 30-hour-threshold was forcing companies, especially smaller ones, into reducing workers' hours in order to avoid having to offer them health insurance or pay the penalty for not offering it. A week later, the committee sent the bill to the full House.
Last Friday, it passed the House, on a largely party-line vote: 18 Democrats voted with nearly every Republican in favor, and 179 Democrats voted against it. Now the bill heads to the Senate, where its future is once again unpromising.
One interesting aspect of the bill is that both its advocates and opponents seem to overstate its potential effects. Advocates claim it will prevent millions of workers who work more than 30 hours a week from seeing their hours cut; opponents argue that implementing the bill would lead to even more workers seeing their hours cut - since many more people work at or above 40 hours a week than 30 - and that they would be left without insurance. In fact, a Congressional Budget Office study has concluded that relatively few employees will be affected by the threshold, wherever it falls.
But the study also found that raising the threshold to 40 hours would add $74 billion to the deficit as more workers seek tax credits to buy their own insurance and fewer companies pay the penalty. And because the premise of the employer mandate rests on a notion of fairness that is widely held among Democrats - employers who don't offer insurance ought to share in the cost of subsidizing insurance for those workers who buy it on their own - relaxing it will be a tough sell to the Senate majority, even though at least one left-leaning pundit has called for repealing the employer mandate altogether.
But back in the House, last Friday's vote is just the latest sign that Republican leaders are turning their energies to fixing, rather than dismantling, the Affordable Care Act, even if their rhetoric insists otherwise. As we reported yesterday, the House recently succeeded in removing the Affordable Care Act's caps on deductibles in small group health plans. (The deductible caps conflicted with another part of the law that sets the terms for cost-sharing in health plans.) And some progressives, like Ron Pollack of FamiliesUSA, are hailing this increasingly flexible turn of events - even if they are dismayed by the fixes that result.
Assessing Who Benefits From the Latest Rulings on the Employer Mandate
Could Employers Use Immigrants to Avoid the Health Mandate?
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
It's Official: No Deductible Caps in Small-Business Health Plans
Ezekiel Emanuel Further Explains His Prediction That Employers Will Drop Health Insurance
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(Taking Note)
June 28, 2012 Thursday
Roberts Hits the Reset Button
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 627 words
HIGHLIGHT: Yes, the Affordable Care Act is constitutional.
The Supreme Court's decision upholding virtually all of the health care reform law (with the exception of a provision on Medicaid that does not really have much practical impact) is a great development, first of all, for Americans. The Affordable Care Act will provide insurance for tens of millions of working people and it will eventually help rationalize and bring down the costs of health care for everyone. This is a huge victory for President Obama at a critical time and a big loss for the right.
The decision also says a lot about Chief Justice John Roberts, who was on the verge of writing himself a reputation after seven years in office as a highly partisan player who was using see-saw majorities to further not just a conservative judicial philosophy but also the broad aims of the neo-conservative wing of the Republican Party.
This week began, however, with Chief Justice Roberts joining the majority in striking down most of Arizona's immigration law and strongly reaffirming the power of the federal government to make immigration policy as part of its overall power to make foreign and national security policy.
Today, Chief Justice Roberts wrote the opinion upholding the Affordable Care Act in its entirety, including the individual mandate to buy health insurance. It's true that he rejected the government's commerce clause defense-that it can impose a mandate under its power to regulate interstate commerce. With this reasoning, he arguably weakened the Commerce Clause itself, which has been the foundation of so many important laws and court rulings in the modern era, including those guaranteeing all Americans' civil rights.
The Chief Justice made it clear from the start, in his testimony at his confirmation hearing, that he would apply a rigorous test for Commerce Clause arguments. "It's not a question of abstract fact," he said, "does this affect interstate commerce or not, but has this body, the Congress, demonstrated the impact on interstate commerce that drove them to legislate."
That part of the ruling could, in the long run, prove even more significant than upholding the health care reform law. But the health care ruling still was momentous, and it's clear that Chief Justice Roberts was instrumental in making that happen. He did so by taking a relatively refined view: The requirement that all Americans buy health insurance is not really a mandate at all, but a tax, and is therefore constitutional since Congress clearly has the power to tax and spend.
As Scotusblog noted this morning, "That is the way Chief Justice John G. Roberts, Jr., was willing to vote for it, and his view prevailed. The other Justices split 4-4, with four wanting to uphold it as a mandate, and four opposed to it in any form."
Chief Justice Roberts could have chosen to ignore that narrow way out and joined the four right-wing judges in striking down the entire law - an act of judicial recklessness that would have been read as an endorsement of Mr. Romney's presidential candidacy. As it is, the Chief justice could hardly be accused of throwing his support to Mr. Obama.
This is going to be hard for right-wingers to swallow, since Chief Justice Roberts was their great standard bearer for conservative judicial and political thought and against "judicial activism." But he has enhanced, in no small way, the reputation of a court whose standing has suffered greatly since Bush v Gore.
The next step for the right is to try to repeal the health care law through the legislative process. Only about an hour after the Court's decision was announced, House Majority Whip Eric Cantor scheduled a vote for July 11.
Five-Four
Whatever Happens, I Will Have Reacted Already
Health Care Confusion
Healthcare: What Might Have Been
Romney's Health Care Plan
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November 17, 2014 Monday
Uber Loves 'Obamacare'
BYLINE: VIKAS BAJAJ
SECTION: OPINION
LENGTH: 300 words
HIGHLIGHT: The head of the company loved by Republicans praised the health reform law.
It should come as no surprise that the chief executive of Uber, Travis Kalanick, likes the Affordable Care Act, a.k.a. "Obamacare." After all, the law is designed to help people whose employers don't provide them with health insurance get coverage through government-run exchanges and subsidies. That is, people like the independent contractors who drive Uber taxis.
But his statement in support of the law, as reported by BuzzFeed News, is attracting attention because some Republican leaders have been trying to make a mascot of Uber as an exemplary capitalist company unfairly targeted by regulation-happy Democrats.It's rather awkward, to say the least, that Uber's chief executive likes the regulation Republicans hate the most. In fact he provided a good summation of why the Affordable Care Act actually benefits the economy, or at least businesses like his, and is not the socialist business-killer of Republican fever dreams.
"The democratization of those types of benefits allow people to have more flexible ways to make a living," Kalanick said at a dinner with a handful of reporters in New York. "They don't have to be working for The Man."
Mr. Kalanick's analysis was, naturally, self-serving. His company's business model is based on organizing, but not providing benefits to, thousands of freelance operators. Whatever steps the government takes to facilitate freelance labor - including making health insurance widely affordable - helps Uber and other similar companies like Lyft and Airbnb do well.
Of course, the idea that Uber fit with the Republican brand was always dubious. As Josh Barro recently wrote in The Times, opposition to Uber often comes from established taxi businesses that are frequently an important constituency for Republican politicians at the local and state levels.
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November 15, 2016 Tuesday
Late Edition - Final
Worse Than Repealing Obamacare
BYLINE: By JONATHAN GRUBER.
Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology, was a health care consultant for the Obama administration.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 31
LENGTH: 762 words
Donald J. Trump made headlines on Friday by saying he would like to keep two components of the Affordable Care Act: allowing young people to stay on their parents' insurance until age 26, and continuing the ban on the exclusion of pre-existing conditions by insurers.
These have long been staples of proposed Republican replacements for the act, but their reaffirmation by the president-elect heightens the importance of understanding what these provisions do, and what they don't.
The ability of young adults to stay on their parents' insurance provided real benefits. It increased coverage by roughly a million people, and improved young people's health. Maintaining this provision is a clear part of any sensible replacement for the Affordable Care Act, and Mr. Trump can do it.
Keeping the ban on insurance companies excluding people with pre-existing conditions, however, is a different story. The problem these patients faced was one of the most pernicious flaws of the individual insurance market pre-Obamacare; their exclusion essentially undercut the entire notion of insurance. How is a breast-cancer survivor meaningfully insured if any costs associated with the recurrence of her cancer, expenses that could run into the hundreds of thousands of dollars, are not covered? So it sounds encouraging that Mr. Trump would continue to ban this behavior.
But let's not kid ourselves. Maintaining this popular provision while scrapping the rest of the health care law would be worse for people with pre-existing conditions than repealing the law in its entirety.
To understand why, let's go back to the world of individual insurance before the major provisions of the Affordable Care Act went into effect on Jan. 1, 2014. In that world, the primary source of profit for insurers was not providing better care so that patients stayed healthy, or negotiating better prices with hospitals and drug companies; it was their ability to avoid the sick and insure only the healthy. And insurers had three tools for doing so: denying coverage to the insured for any costs associated with pre-existing conditions; denying insurance entirely to sick people; and charging the sick much higher prices than the healthy, a practice called health underwriting.
If Mr. Trump preserves just the ban on the first of these tools, and allows insurers to reintroduce the other two, he has effectively done nothing. That's because any insurer can simply use the other tools to accomplish the same goal as it could with all three.
Suppose a breast-cancer survivor applied for insurance in Mr. Trump's post-Obamacare world. It's true that the insurer could not offer her coverage that didn't include breast-cancer treatments. But the insurer could simply not sell her coverage at all.
Alternatively, the insurer could offer coverage, but say that any breast-cancer survivor had to pay, say, five times more than everyone else. Both would be perfectly legal if the Affordable Care Act was repealed and replaced under Mr. Trump's principles. If we say that insurers have to pay for breast-cancer treatment for their insured, but allow them to set unaffordable prices or deny insurance altogether, how does that solve the problem?
In fact, Mr. Trump's idea would make insurance markets function even worse than they did before Obamacare. Back then, an otherwise-healthy breast-cancer survivor could at least get insurance coverage for medical expenses not related to her cancer. If Mr. Trump followed through with his suggestion, that would not be possible: The insurer would simply deny coverage altogether rather than take the risk of being forced to pay for treatment for a recurring breast cancer.
So Mr. Trump would not only continue the insurance discrimination that plagued the country before the Affordable Care Act but even make it worse.
In fact, there is simply no Republican replacement for the act that wouldn't leave millions of Americans at serious financial risk. The single most important accomplishment of the Affordable Care Act was to bring the United States into line with the rest of the developed world, as a place where people were not one bad gene or one bad traffic accident away from bankruptcy.
Mr. Trump and other Republicans can discuss kind-sounding alternatives as much as they like, but they can't hide the fact that repealing the fundamental insurance protections that are central to the act would be a cruel backward step.
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URL: http://www.nytimes.com/2016/11/15/opinion/what-could-be-worse-than-repealing-all-of-obamacare.html
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(First Draft)
October 2, 2014 Thursday
McConnell Vows More Health-Law Votes if G.O.P. Takes Senate
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 286 words
HIGHLIGHT: If Republicans gain control of the Senate, one thing is for sure: more votes to dismantle President Obama’s health law.
If the Republicans gain control of the Senate, one thing is for sure: more votes aiming to dismantle President Obama's health law.
Senator Mitch McConnell of Kentucky said as much on Thursday in an editorial board meeting with The Cincinnati Enquirer that was streamed live on its website.
Although Mr. McConnell was realistic that Republicans will have little chance of repealing the Affordable Care Act while Mr. Obama is president, he said that he would put Democrats on the spot to repeal provisions such as the new tax on medical devices and a change in the definition of full-time work to 40 hours from 30 hours.
"At the very least we'd like to give our Democratic colleagues a chance to vote again on the medical device tax," Mr. McConnell said. "If I'm setting the agenda next year, we'll give everybody a chance to vote on it."
Despite the fact that the Affordable Care Act is popular in Kentucky, Mr. McConnell maintained that it was the worst piece of legislation that had been passed in the United States in the last 50 years.
Republican leaders have said that they will need to change their mentality if they retake control of the Senate, no longer being the "party of no." They are also likely to focus on legislation on the approval of the Keystone XL pipeline, on an endorsement of natural gas exports and on a veterans employment bill.
Mr. McConnell has made the prospect of being the majority leader a part of his pitch to voters in Kentucky.
"The majority leader of the Senate sets the agenda and determines what we're going to debate," Mr. McConnell said on Thursday. "It would be a great advantage of Kentucky to have a Kentuckian setting the agenda, rather than a guy from Nevada."
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August 19, 2015 Wednesday
Late Edition - Final
Walker Pushes Tax Credits to Replace Health Law
BYLINE: By ALAN RAPPEPORT
SECTION: Section A; Column 0; National Desk; FIRST DRAFT; Pg. 17
LENGTH: 784 words
''Repeal and replace'' has been a mantra for Republicans when discussing President Obama's health law. On Tuesday, Gov. Scott Walker, the Republican presidential candidate from Wisconsin, offered some details on how he would replace the Affordable Care Act if he is elected.
Mr. Walker's plan makes a full repeal of the law his top priority, then proposes a system of tax credits that would allow Americans who do not get health insurance through their employers to purchase individual plans. The credits would be based on age, and consumers could then decide what plan to purchase, if they opt to buy health insurance at all.
''On my very first day as president of the United States, I will send legislation to the Congress to once and for all repeal Obamacare entirely,'' Mr. Walker said in a speech in Minnesota.
Repealing the Affordable Care Act has been a rallying cry for Republicans since it was enacted without their support in 2010. Mr. Walker's detailed critique of the law and his plan to replace it by lowering taxes and offering consumers more freedom comes as he has been struggling in recent polls after a tepid debate performance.
Despite continuing resistance to the law, dismantling it would likely be a big challenge for a Republican president. The Obama administration said this month that the number of people without health insurance had continued to decline, dropping by 15.8 million, or a third, since 2013. Meanwhile, studies have shown that the law has helped to keep insurance premiums in check.
''If this vague grab-bag of conservative wish-list items is the best health plan the G.O.P. can come up with for the largest economy on earth, it's the clearest signal yet that Republicans like Scott Walker are out of ideas and out of touch,'' said Eric Walker, a spokesman for the Democratic National Committee.
Senator Marco Rubio shed some light on his own health care reform policy this week. The Republican from Florida would also promote tax credits as a way to make insurance affordable and create federally backed ''high risk pools'' in states so that the sick can buy insurance at reasonable prices.
In Wisconsin, Mr. Walker has been a staunch opponent of the Affordable Care Act and has resisted taking federal funds to expand Medicaid in the state. A report last year faulted him for costing Wisconsin $500 million in lost savings because of his opposition to the law, but the governor maintained that such reliance on federal money would have been a mistake.
''We believe confidently going forward this federal government is likely to renege from its promises on Medicaid to the states,'' he said last summer. ''And we won't be exposed to that.''
Mr. Walker vows to do away with the Affordable Care Act's requirement that Americans purchase health insurance. Instead, his plan would seek to limit insurance premiums by opening the market so that consumers can shop for plans across state lines, thus intensifying competition among insurance companies.
The proposal also calls for reforms to Medicaid and improvements to health savings accounts that would give patients more pretax money to pay their health bills.
''You're going to do more to manage your health care, and your health, not just your health care, if you have control over the those dollars,'' Mr. Walker said. ''It's all about freedom.''
Mr. Walker also tries to address the issue of covering people with pre-existing conditions, which was one of the most important reforms in the Affordable Care Act because of the prohibitive prices sick people often faced when trying to purchase health plans. He promises ''additional reforms to insurance coverage laws'' that would prevent companies from discriminating against people who find themselves ill and without health insurance. Federal funds would be distributed to the states to help people with these conditions buy coverage.
Many of Mr. Walker's proposals on overhauling the health care system have been mainstays for Republicans over the years, and his plan offers little insight into how its costs or effect on the economy would compare with Obamacare. But pointing to the success of Wisconsin's BadgerCare program for the poor, Mr. Walker said he was confident that a similar structure could work across the United States.
''My plan would roll back the damage done by Obamacare and when compared to the realities that existed before Obamacare, would not add to the deficit,'' he said.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/politics/first-draft/2015/08/18/scott-walkers-health-care-plan-relies-on-tax-credits-to-buy-coverage/
LOAD-DATE: August 19, 2015
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GRAPHIC: PHOTO: Gov. Scott Walker of Wisconsin on Tuesday presented his plan to replace the health care law at a machine parts plant in Brooklyn Center, Minn. (PHOTOGRAPH BY JIM MONE/ASSOCIATED PRESS)
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(First Draft)
November 17, 2014 Monday
Billions of Dollars Mend Health Insurers' Rift With Obama
BYLINE: FIRST DRAFT
SECTION: US; politics
LENGTH: 46 words
HIGHLIGHT: Once a favorite political punching bag for President Obama, the health insurance industry has reaped big benefits from the Affordable Care Act.
Once a favorite political punching bag for President Obama, the health insurance industry has reaped big benefits from the Affordable Care Act.
The Times's Robert Pear explains how the law has brought the two unlikely allies together:
Health Law Turns Obama and Insurers Into Allies
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The New York Times
January 14, 2017 Saturday
Late Edition - Final
House Clears Path for Repeal of Health Law
BYLINE: By THOMAS KAPLAN and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1114 words
WASHINGTON -- The House cleared the way on Friday for speedy action to repeal the Affordable Care Act, putting Congress on track to undo the most significant health care law in a half-century.
With a near party-line vote of 227 to 198, the House overcame the opposition of Democrats and the anxieties of some Republicans to approve a budget blueprint that allows Republicans to end major provisions of President Obama's health care law without the threat of a Democratic filibuster in the Senate.
President-elect Donald J. Trump, Speaker Paul D. Ryan and other Republican leaders now face a much bigger challenge: devising their own plan to ensure broad access to health care and coverage while controlling costs. While their party is far from a consensus on how to replace the health care law -- under which more than 20 million Americans have gained health insurance -- they will need votes from Democrats in the Senate to enact a robust replacement plan.
Republicans have argued that Americans have been crushed by soaring premiums and other unintended effects of the law, which was adopted without any Republican votes.
''This is a critical first step toward delivering relief to Americans who are struggling under this law,'' Mr. Ryan said, adding, ''This experiment has failed.''
Democrats warned that repeal of the health law would cause hardship for millions of Americans and create chaos in insurance markets and in the health care system, which accounts for about 18 percent of the nation's economy.
''If we go down this path, we won't have repeal and replace,'' said Representative John Yarmuth of Kentucky, the senior Democrat on the House Budget Committee. ''What we'll have is repeal and repent because we're going to owe a huge apology to the American people for the damage that we cause.''
Representative Suzan DelBene of Washington, a Democrat, said, ''There's still no plan for what comes next, threatening massive disruption to the entire health care system.''
In the days before the House vote, some conservative Republicans, as well as moderates, expressed discomfort about signing off on the budget blueprint without having a clearer picture of how and when Republican leaders planned to replace the health care law. Nine House Republicans ended up voting against the budget measure on Friday. No Democrats voted for it.
The Senate approved the same measure early Thursday by a vote of 51 to 48. The House and Senate votes this week -- essentially procedural steps -- represented the first of several moves that Republicans plan to make as they work to unwind the health care law.
In the coming weeks, they say, they will try to devise a replacement, working closely with Mr. Trump and his choice to lead the Department of Health and Human Services, Representative Tom Price of Georgia.
Four committees -- two in the Senate, two in the House -- will write language repealing major provisions of the 2010 health law. The resulting legislation can be passed with simple majorities in both chambers, and will be immune to a Democratic filibuster in the Senate.
Then, Republicans say, they will pass one or more free-standing bills to replace selected provisions of the Affordable Care Act. In the Senate, where Republicans hold 52 seats, they will need help from Democrats to reach the 60 votes necessary to approve such legislation.
Mr. Trump voiced support this week for repealing and replacing the health care law ''essentially simultaneously,'' though it remained to be seen if Republicans in the Senate can win enough Democratic support to adopt a replacement for the existing health care law, given the need to reach 60 votes.
In the House debate on Friday, Republicans and Democrats offered wildly differing views of health care and health insurance.
Representative Jason Lewis of Minnesota, a first-term Republican, said he had firsthand experience with the Affordable Care Act.
''Minnesotans have seen their health insurance choices shrink while their premiums, co-pays and deductibles skyrocket,'' Mr. Lewis said. ''I should know. For the last, in fact, over five years, I've been in the individual market, and my own insurance premiums have nearly tripled, and I've gone through three insurers. Minnesotans have seen a 50 to 67 percent increase in the premium cost this year alone.''
The House Democratic leader, Representative Nancy Pelosi of California, who helped engineer passage of the health law, defended it on Friday, saying that every American benefited.
''The Republicans are feeding their ideological obsession with repealing the A.C.A. and dismantling the health and economic security of hard-working families,'' Ms. Pelosi said. For six years, she said, Republicans have had the chance to put forth an alternative, but ''we've seen nothing.''
Echoing their colleagues in the Senate, Democrats asked how Republicans planned to go about replacing the Affordable Care Act -- a complex, arduous task, as Democrats know from their own experience developing and passing the health law in the first place.
''When you put pen to paper, all hell is going to break loose on your side,'' said Representative Peter Welch, Democrat of Vermont.
Democrats also tried to draw attention to what they said would be the devastating consequences of repealing the health care law.
Over and over, after a Republican member spoke out against the law, Mr. Yarmuth offered several data points specific to the member's home state, including how many people would lose their health coverage.
Republicans, though, were eager to deliver on a central campaign promise. ''The public has rendered judgment on this health care law,'' said Representative John Shimkus of Illinois.
The differing views among House members on Friday foreshadowed the acrimony that is all but certain in the weeks to come, as Republicans press ahead with their repeal efforts over Democrats' strenuous objections.
So far, lawmakers have shown some creativity in trying to explain the wisdom -- or lack of wisdom -- in moving forward with a repeal.
On Friday, Representative Drew Ferguson of Georgia, a freshman Republican, likened the health care law to a goat that had been let loose in a person's home.
''Now for six years, that goat has been messing in and destroying my house,'' he said. ''I want to renovate my house, but before I can, I have to get the goat out of the house before it does any more damage. It makes no sense to start fixing up my house until we get the goat out.''
Voting for the measure on Friday, Mr. Ferguson said, would get rid of the goat.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/01/13/us/politics/affordable-care-act-congress-budget.html
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GRAPHIC: PHOTOS: Representative Trey Gowdy and other House Republicans voted on Friday on a blueprint toward repeal of the Affordable Care Act. (A1)
Representative Kevin McCarthy of California, above, the majority leader, and other House Republicans on Friday made steps toward a repeal of the Affordable Care Act. Representative Nancy Pelosi of California, left, defended the 2010 health care law. (PHOTOGRAPHS BY AL DRAGO/THE NEW YORK TIMES) (A12)
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(First Draft)
June 25, 2015 Thursday
Verbatim: Justice Scalia Coins Health Law Word - Scotuscare
BYLINE: FIRST DRAFT
SECTION: US; politics
LENGTH: 39 words
HIGHLIGHT: “We should start calling this law Scotuscare.” — Justice Antonin Scalia, in his dissenting opinion on the Affordable Care Act subsidies case.
We should start calling this law Scotuscare."
- Justice Antonin Scalia, in his dissenting opinion on the Affordable Care Act subsidies case decided at the United States Supreme Court..
Supreme Court Allows Nationwide Health Care Subsidies
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(Economix)
October 21, 2013 Monday
Medicaid and the Incentive to Work
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 669 words
HIGHLIGHT: With Medicaid’s expansion under the Affordable Care Act, an Oregon study finds little impact on the labor market from Medicaid coverage.
The Affordable Care Act is - to state the obvious - aimed at bolstering insurance coverage in the United States. But the law is so big that it will necessarily have widespread economic ramifications, economists think, including an effect on the labor market.
For instance, the Congressional Budget Office has surmised that the law may lead more workers to choose early retirement, since they would not fear losing their insurance coverage if they did so. It might also lead certain employers to hire more part-time workers, to avoid the so-called "employer mandate." (There is no evidence that is happening yet, and the effect would most likely be small in a labor force of 156 million, by the way.)
But economists and policy researchers have been divided on the effect that the Medicaid expansion in the health care law might have on workers. Amy Finkelstein, a professor at the Massachusetts Institute of Technology and a recipient of the John Bates Clark Medal for young economists, laid out the arguments. "People have made the argument that expanding Medicaid could be great stimulus, by improving people's health and productivity and security, and making it easier for them to find employment," she said in an interview. "Others have argued the opposite: People were seeking employment in order to get access to health insurance, and they might stop working" once covered by law.
A new paper - the latest to come out of the famed Oregon Health Insurance Experiment - finds that neither of those arguments seems to hold up. Medicaid turns out to have little short-term effect on the labor-force participation or earnings of low-income Americans.
It is worth stepping back for a moment to understand why the Oregon study is unique. Back in 2008, Oregon, like many states, did not provide Medicaid coverage to all poor adults. (Generally, adults qualified only if they had a disability or a dependent child, no matter how poor they were.) The state found itself with enough money to cover some, but not all, of those uncovered adults. It decided the fairest way to allot the coverage would be through a lottery.
That gave researchers a rare opportunity to isolate the effects that insurance coverage - and insurance coverage alone - had on the lives of its recipients. A team of all-star researchers surveyed lottery winners and losers, and compared them. Prior papers coming out of the study have found that Medicaid coverage increased health spending and financial security, but had a limited effect on health outcomes in the short term.
In a new batch of findings, Ms. Finkelstein and her co-authors say that Medicaid had no significant effect on labor-force participation or earnings. That means that the newly covered were not leaving or joining the labor force much more than their uncovered peers were, nor were they making much more or less. (The nitty-gritty result: "Our 95 percent confidence intervals allow us to reject that Medicaid causes a decline in labor-force participation of more than 4.4 percentage points, or an increase of more than 1.2 percentage points.") The study also found that Medicaid increased enrollment in the food-stamp program, but did not have much effect on the receipt of other government benefits, including disability and welfare.
What might the lessons be for the half of states currently expanding their Medicaid programs, including Oregon? (It is joining the federal expansion in the Affordable Care Act, meaning it will cover all poor adults.) Well, Oregon a few years ago is not the United States today. And the Oregon study looks at relatively short-term effects of the Medicaid expansion, not measurements like lifetime earnings. But it would be reasonable to think that those states might see similar effects after expanding their programs, too.
The Hurdles to Success for the Affordable Care Act
Little Sign of Jobs Impact From Health Care Law
The Tax Equation in the Health Care Law
Obamacare vs. Romneycare: The Labor Impact
Breaking Out of a Cramped Economic Policy Debate
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October 27, 2013 Sunday
Late Edition - Final
The Dawn Of Obamacare Hasn't Hurt Insurers' Stocks
BYLINE: By ANNA BERNASEK
SECTION: Section BU; Column 0; Money and Business/Financial Desk; DATAPOINTS; Pg. 7
LENGTH: 308 words
The Affordable Care Act has been controversial -- so much so that Republican objections to it were a principal cause of the recent partial shutdown of the federal government.
Yet from the financial perspective of the health care industry, Obamacare, as the law is often known, doesn't seem much of a hindrance.
In fact, it may even turn out to be positive.
Consider the situation of health insurance providers.
Because they face new regulations intended to broaden coverage and limit profit-taking, some analysts have been concerned that profits will suffer. But in the run-up to the Affordable Care Act, stock market prices have told a different story.
Over the last 12 months, shares of the top five publicly traded health insurance companies -- Aetna, WellPoint, UnitedHealth Group, Humana and Cigna -- have increased by an average of 32 percent, while the Standard & Poor's 500-stock index has risen by just 24 percent.
Strong profits in the current year, as growth slowed in overall health care costs, is one probable explanation for the outperformance by the group.
Another is the growing expectation that payments from new customers required to buy insurance under the Affordable Care Act will offset costs from new regulations.
Health insurance companies themselves haven't exactly sounded an alarm about the Affordable Care Act's arrival.
Mark T. Bertolini, the Aetna chief executive, said recently: ''We continue to believe that public exchanges can represent a longer-term upside opportunity.''
And most health insurers are forecasting earnings growth after the health care law is fully in effect.
David Cordani, Cigna's chief executive, said his company's average annual earnings per share would grow 10 to 13 percent over the next three to five years.
If such projections are correct, someday we may look back and wonder what all the fuss was about.
URL: http://www.nytimes.com/2013/10/27/business/insurers-stocks-unhurt-by-the-dawn-of-obamacare.html
LOAD-DATE: October 27, 2013
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GRAPHIC: GRAPHICS: +32% Average stock price of five major health insurers
+24% Standard & Poor's 500 (all for 12 months ended Friday)
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November 18, 2014 Tuesday
Regulators Warn Against Reimbursing Employees for Health Premiums
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 956 words
HIGHLIGHT: Even now, however, the issues remain complex and open to interpretation.
Since the implementation of the Affordable Care Act, many small businesses have been intrigued by the possibility that they might be able to stop dealing with health insurance entirely and instead offer their employees a stipend to go buy insurance on the individual exchanges. But in a clarification issued in early November, the federal government appears to have taken a stand against that strategy.
There had been little doubt among most lawyers who follow the tax implications of the Affordable Care Act that a company would not be able to subsidize its employees' individual health insurance with pretax dollars (the way that premiums for group health insurance are excluded from an employee's income). But as we reported a few weeks ago, the government's guidance on using post-tax compensation was murkier. With its recent statement, the government removed some - though not all - of that ambiguity.
The additional clarity came in the form of a "frequently asked questions" document issued by the Department of Labor. Even now, however, the issues remain complex and open to interpretation, and the tax and benefits lawyers contacted by You're the Boss offered differing perspectives on the Labor Department's answers. What better way to try to make sense of these issues than to borrow a trope from the government and present them in the form of an FAQ.
Q.
So, can a company reimburse workers for their insurance premiums with after-tax money?
A.
No. Any reimbursement scheme constitutes a group health plan, according to the Labor Department. This designation is important, because the government had already decided that a group health plan must comply with certain market reforms in the Affordable Care Act, including one that bans dollar limits for certain benefits. And a plan that reimburses members for individual policies simply cannot comply with those requirements, according to the agencies.
Businesses with plans that violate the health law's market rules can face penalties of up to $36,500 a year for each affected employee.
Up until now, there had been a debate among lawyers about whether a company could expressly reimburse individual insurance premiums with taxable income, or, if not, condition the additional compensation on buying insurance - even if the money is not tied directly to the cost of premiums. But the latest advice from the Labor Department should end those arguments, according to four of five lawyers contacted by You're the Boss.
"What we know now is that you can't condition the receipt of after-tax money only on the purchase of insurance," said Christopher E. Condeluci, a Washington-based lawyer. "Instead, you have to give the employee the choice between taking the money as cash wages or allocating that money toward the purchase of insurance."
The one lawyer we talked to who disagreed is Seth Perretta, who represents a number of large business organizations with a stake in the various rule-makings of the Affordable Care Act. "I can condition employment on all sorts of things," Mr. Perretta said. "I can condition a subset of compensation on all sorts of things, on the employee doing lawful acts. I think it really turns on whether the regulators would agree that so long as the amount I'm paying to you is not directly related to the amount you pay for insurance, whether or not disconnecting the two would allow me to treat that as a taxable wage." Even Mr. Perretta said the answer was still not clear.
Q.
Suppose an owner just gives raises and doesn't specifically reimburse premiums? Can the owner tailor the amount of additional compensation for each person to the cost of health insurance without crossing the line into reimbursement?
A.
Yes, at least if the owner gives the raise unconditionally. (Mr. Perretta said it was unclear whether correlating a conditional raise would be permissible because "we are in uncharted territory.") For example, the raises could follow the government's age curve that sets the relative cost for premiums in the individual market. "Employee pay rates and raises are subject to various employment non-discrimination rules but, other than that, employers have wide discretion in setting pay," said Linda Mendel, a lawyer in Columbus, Ohio. It is not illegal, by the way, to discriminate in favor of older workers.
Q.
What about Zane Benefits, which is promoting a plan it says allows companies to reimburse employees who buy individual insurance with pre-tax dollars - and even lets lower paid employees who qualify claim federal subsidies when they buy their insurance on the exchanges. How is this possible?
A.
It is not, at least according to federal regulators. The recent guidance did not mention Zane by name, but it referred to the type of plan it uses (a Section 105 plan, after that section of the tax code) and said that it, like other reimbursement plans, was subject to the Affordable Care Act's insurance market reforms but cannot comply with them because of the reimbursement mechanism. Moreover, the Labor Department declared, "employees participating in such arrangements are ineligible for premium tax credits (or cost-sharing reductions) for Marketplace coverage."
Zane, for its part, published its own FAQ in response to the Department of Labor FAQ. In it, Zane insisted that its plan complies with the health law and that businesses that use it can rest assured that their employees can qualify for exchange subsidies. "This is nothing new," Rick Lindquist, Zane's president, wrote in an email about the Labor Department's guidance.
All of the lawyers we've talked to disagree with Zane's legal reasoning, but until one side or the other forces a resolution of the issue, it will be Zane's word against the government's.
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(Economix)
February 19, 2014 Wednesday
The Employer Mandate: Dukakis All Over Again
SECTION: BUSINESS; economy
LENGTH: 671 words
HIGHLIGHT: The delays in carrying out various aspects of the Affordable Care Act are eerily similar to those of a Massachusetts health care law passed in 1988 at the urging of Gov. Michael Dukakis, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Last week's adjustment to the employer mandate represents another battle in the political war of attrition between employers and those who want to carry out the federal health reform law. A similar war was fought in Massachusetts in the years after the Michael Dukakis administration and continued for decades.
In 1988, Governor Dukakis pushed through a law (not to be confused with the health law signed by Gov. Mitt Romney almost two decades later) that sought to achieve universal health insurance coverage in Massachusetts with a legislative package that included a $1,680 penalty per employee per year on employers who did not provide health coverage to their employees.
The Dukakis package passed by a narrow margin; to get it through the legislature, the law provided for a 45-month delay before the employer mandate took effect. (I recommend a book and a paper by John E. McDonough chronicling his health reform efforts as a Massachusetts legislator.)
Forty-four months after passage, the Massachusetts mandate was delayed three more years by a new law passed by the legislature over Gov. William Weld's veto. The employer mandate was delayed twice more. As the fourth date approached for carrying out the 1988 employer mandate, the legislature repealed it entirely.
The employer mandate would return again in 2006 under Governor Romney, with its penalty set at one-tenth that of the Dukakis law.
These events are shown in the timeline below. Red shapes are dates of legislation and blue shapes are dates for putting the legislation into effect. The Massachusetts timeline is on the left, and that for the federal Affordable Care Act, which was passed in March 2010, on the right. (For both laws, month zero is when the law was passed). The timeline for the Affordable Care Act has a number of parallels with that of the Dukakis law. Both laws originally provided for an employer mandate delay: 45 months in Massachusetts and 46 months for the federal law.
In both cases, the employer mandate was delayed as the original effective date approached and businesses complained. The first federal delay was announced in the 40th month subsequent to the original law; the first Massachusetts delay was enacted in the 44th month.
In both cases, a second delay was announced, but it did not happen in Massachusetts until Month 80. Last week, already in Month 47 of the law, the federal government announced a second delay of the full employer mandate until January 2016 (which will be Month 70). So far, it looks as though a few employers will pay a reduced penalty as early as next January.
Both laws were passed when Democrats held the executive position and a majority in the legislature. In both cases, one-party rule ended soon after the health law was signed.
In Massachusetts, the legislature took the initiative to delay the employer mandate and carried out its decision as new laws. Federally, the Obama administration made the delays by notifying employers that the penalty either would not be enforced or would be enforced to a lesser degree than the original law specified..
The penalty amounts in the two laws are also similar. Adjusted for inflation, the Dukakis law's penalty (federal tax deductible) was equivalent to a $2,791 penalty in 2014. The federal law's penalty in 2014 would have effectively been $3,046 because it is not deductible from an employer's business taxes.
One hundred months after the Dukakis law was passed, its employer penalty was finally repealed. If the federal law were to follow the same timeline, it would be repealed in June 2018, in the second year of a new presidency.
The Economics of Being Kinder and Gentler in Health Care
The Slow Death of the Employer Mandate
The Hurdles to Success for the Affordable Care Act
Dealing With Drafting Errors in the Health Care Law
Obamacare vs. Romneycare: The Labor Impact
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(First Draft)
November 10, 2014 Monday
Lower Projections for Health Law
BYLINE: FIRST DRAFT
SECTION: US; politics
LENGTH: 104 words
HIGHLIGHT: Enrollment for health insurance purchased through the Affordable Care Act’s exchanges is not expected to be as robust next year as previously projected.
Enrollment for health insurance purchased through the Affordable Care Act's exchanges is not expected to be as robust next year as previously projected.
The Department of Health and Human Services estimated that by the end of 2015, a total of 9 million to 9.9 million people would have coverage purchased through insurance exchanges under President Obama's health care law.
By contrast, the Congressional Budget Office had estimated that 13 million would be enrolled next year, with the total rising to 24 million in 2016.
The Times's Robert Pear has the full story:
U.S. Gives Modest Forecast for Enrollments Under Health Law
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The New York Times
December 10, 2016 Saturday 00:00 EST
Should I Lie About My Beliefs to Get Health Insurance?;
Opinion
BYLINE: HILLARY ROSNER
SECTION: OPINION; sunday
LENGTH: 1342 words
HIGHLIGHT: I could save thousands by joining a faith-based plan. But I would have to denounce gay marriage and women's right to an abortion.
Boulder, Colo. - HERE'S an ethical dilemma. If you could save your family more than $8,000 next year simply by signing a statement affirming belief in principles you find repugnant, would you?
It sounds absurd. But in fact that's the position I'm in this week, thanks to a loophole in the Patient Protection and Affordable Care Act, otherwise known as Obamacare. My health insurance poses a financial hardship to my family. All I have to do to lower my yearly bills by thousands of dollars is use my John Hancock to denounce gay marriage and a woman's right to control her reproductive destiny.
By Dec. 15, like many Americans, I need to choose a new health insurance plan for 2017. I am a freelance journalist and editor. My husband runs a small business that pays him a salary but no benefits. We are among the millions of Americans who, under the Affordable Care Act, buy individual insurance through an increasingly expensive and inadequate marketplace. Since the law went into effect, monthly premiums for my family of three have already more than doubled, from $450 a month to $930. (In Colorado, my home state, 2017 rates are on average 20 percent higher than they were in 2016; in some counties that number is 40 percent.) On top of that, high deductibles mean we pay for nearly everything ourselves. In 2016, between monthly premiums and out-of-pocket costs, we've spent roughly $20,000 on health care.
Our new plan, the fourth in four years, is being discontinued, so we must again seek new insurance. We don't qualify for federal subsidies. I've got six months of 2015 insurance premiums accruing interest on a credit card, and a $4,200 bill for a four-hour emergency room visit sits menacingly on my desk. The number of insurers offering individual plans in Colorado, as in many other states, has dwindled; there are now only three companies - Anthem, Cigna and Kaiser - left in our ZIP code. (In 14 Colorado counties, there is only one provider offering plans.) Only one of our longtime doctors participates in any of these 2017 A.C.A.-plan networks.
I support the Affordable Care Act. Before it took effect, my husband was once denied coverage on the grounds that he'd seen a doctor for a sinus infection; I was charged hundreds of dollars above the quoted rate because of a long-ago surgery with no lasting health impacts. I know people whose lives the Affordable Care Act has transformed, friends with pre-existing conditions that had made them uninsurable but who now can get the coverage they need. My support for the law comes from a belief that access to affordable health care should be an undeniable right. But the battle to get it passed produced a deeply, perhaps fatally, flawed law - and on a personal level, my quality of life has declined under the A.C.A.
There are now a growing number of theoretically less expensive health care options that don't comply with the Affordable Care Act. I could, for instance, join a local membership-based primary care provider clinic - around $200 a month for a family of three - and combine it with a similarly priced catastrophic-coverage plan. But these options still leave gaps in your coverage, and subject you to a fine for not carrying proper insurance - up to 2.5 percent of your adjusted gross income.
There is, though, one more option available to me. For only $500 a month - a saving of $8,400 a year in premiums over the Anthem plan we are considering - I could purchase coverage through a "faith-based plan" called Altrua HealthShare. Officially known as "health care sharing ministries," such plans are not, strictly speaking, insurance. According to the Alliance of Health Sharing Ministries, "The purpose of the ministry is simply to organize other people who voluntarily choose to help fellow members pay their medical bills in keeping with biblical commands to 'share one another's burdens.' "
But in practice, the ministries serve much the same function as insurance. Members pay a monthly contribution, they are subject to an annual deductible (in this case, $1,000 per person) and their doctor submits a claim and is reimbursed by the plan.
Faith-based plans do not adhere to the same rules as Obamacare insurance plans. They don't have to pay for preventive care, they may not insure smokers, they may not cover pre-existing conditions, and they may deny you admission based on your weight. If you are a 5-foot-6 woman and weigh more than 230 pounds, for instance, Altrua HealthShare won't offer you membership. Unlike the other non-A.C.A.-compliant options, though, health care sharing ministries are actually exempt from the law. (These organizations have to meet certain requirements, and must have been in existence continuously since 1999.) That means if you sign up for one, you aren't subject to the fines.
While some health sharing ministries require membership in a Christian congregation, Altrua HealthShare does not. My family's doctors all participate in its extensive network. According to its guidelines, membership "is based on a religious tradition of mutual aid, neighborly assistance and burden sharing." Sounds promising. Membership, Altrua's brochure continues, "is specifically tailored for individuals who maintain a healthy lifestyle, make responsible choices in regards to health and care, and believe in helping others." I bike, hike and practice yoga; I'm a longtime vegetarian; I've never smoked. And who doesn't believe in helping others?
Here's the catch. In order to join, you have to agree to a "statement of standards." Among the list of seven principles are these three: "According to the Word of God, sexual relations outside the bond of marriage is morally wrong." "Marriage is a bond between a man and woman only." "Abortion is wrong, except in a life-threatening situation to the mother."
I disagree with each of these. And the last I checked, premarital sex, same-sex marriage and abortion were legal in the United States. Still, I considered consenting to the "standards" for the sake of my family's financial situation. Imagine if we could put money away for college tuition, or pay down our credit card debt, instead of sending thousands to a giant corporation. What if I swallowed my principles and sent a contribution to Planned Parenthood as penance?
But in the end, I simply couldn't do it. Much like many of these ministries' members, I believe certain principles are sacred. (Altrua won't pay maternity benefits if the pregnancy arose through "adultery or fornication by the member.") For those on the religious right, their beliefs grant them exemption from federal law, and access to decent affordable health care. Unfortunately, there's no such loophole for clean-living, charitable nonbelievers.
So next week, I will sign up for a plan that costs nearly $1,200 a month and that will still pay for next to none of my family's medical needs. I will have to part ways with the O.B. practice whose doctors saw me through a complicated pregnancy and delivered my son healthy. Because I hold one set of beliefs about right and wrong, I am subject to federal law. If I subscribed to a different set of morals, I would be exempt from its clutches.
Roughly 625,000 people belonged to health sharing ministries as of September; that number is sure to rise as people like me balk at their diminishing options. As Republicans grapple with the Affordable Care Act, it would be wise for them to keep in mind that, like it or not, America is composed of people with different backgrounds, ethnicities and beliefs. The answer is not to repeal the law, which could result in more than23 million Americanslosing their coverage. The answer is to find solutions that allow all working families to find affordable health care that doesn't demand choosing between their ethics and their ability to provide for their children.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for theOpinion Today newsletter.
Hillary Rosner is a freelance journalist who reports about the environment.
DRAWING (DRAWING BY ADAM MAIDA)
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November 19, 2014 Wednesday
Chasing the Entrepreneurial Opportunity in Affordable Care Act
BYLINE: STEVE LOHR
SECTION: TECHNOLOGY
LENGTH: 943 words
HIGHLIGHT: The Affordable Care Act has opened up entrepreneurial opportunities for start-ups like Stride Health, a recommendation engine for health insurance.
Some foes of the Obama administration's Affordable Care Act portray the law as nothing less than socialist-style government control of American health care. Noah Lang, a health care entrepreneur, is not one of those people.
Mr. Lang, chief executive of Stride Health,explains that the Affordable Care Act is one of two major developments in the last few years that have made it possible for a company like his San Francisco start-up to exist. The other big force, he says, is the explosion in available health data, led by government initiatives, notably HealthData.gov.
Stride Health has created a recommendation engine for individuals and families buying health insurance. It packs in a lot of personalization in its recommendations, going well beyond premium rates and standard quotes. Stride Health predicts what a household's actual health care costs are likely to be in a given year.
Its software makes those calculations based not only on age, location and gender, but also health conditions, personal history and drugs taken - taking into account premiums, deductible payments and government subsidy payments, if a person or family qualifies. It allows a person to figure in the likely costs of injuries like a dislocated shoulder or life events like a pregnancy. Some of the information it pulls in automatically, and other data is submitted by users.
Stride Health began offering its recommendation service in California earlier this year. Now, as the sign-up period for health insurance on federal and state exchanges gets underway, Stride Health is bringing out a mobile app version of its recommendation service. The service includes the major insurers and some smaller plans in six states representing 40 percent of the nation's population: California, New York, Florida, Texas, Pennsylvania and Illinois.
The federal and state exchanges offer the same insurance plans, but not Stride Health's personalized recommendations and detailed cost predictions. "We think of the exchanges as our partners," Mr. Lang said. "We can take some of the load off them," he added, in a nod toward the delays and confusion people encountered on the online exchanges last year.
The Affordable Care Act, Mr. Lang explained, has changed the rules for insurance underwriting and opened the door to giving individuals far more bargaining power in purchasing health coverage. Under the legislation, insurers are mostly permitted to ask two questions of prospective customers: age and location.
Previously, an individual or family applying for insurance could be asked all kinds of questions about medical conditions, family history and lifestyle. That system was known as "individual underwriting," and information was collected by the insurer to tailor prices and terms.
"That's off the table now," Mr. Lang said. He views Stride Health as turning the table in the health-insurance marketplace, by collecting information on behalf of individuals to give them a leg up when buying insurance.
Before founding Stride Health last year, Mr. Lang spent five years as a vice president of business development at Reputation.com, a service to control the use of personal information and protect the privacy of its customers. So he has seen how personalization is used online for marketing - and sometimes against people.
"But there is little personalization on the web in health care for the user and buyer," he said. "Health care is lagging a decade behind the rest of the web."
His co-founder, Matt Butner, Stride Health's chief technology officer, came from online advertising and marketing and he worked on recommendation features used at Netflix and Priceline.
The many data sets Stride Health blends in its predictions, Mr. Lang said, allow it to make recommendations based on the health outcomes of many people with similar characteristics and histories. And he compares the approach to weather prediction. Tomorrow's forecast, he noted, is based partly on today's weather. But the prediction also pulls in data on weather patterns for months and years in a location.
"We couldn't have done this even a few years ago," Mr. Lang said.
HealthData.gov got underway about five years ago. Seeing that little was being done with government health data, the Obama administration gathered 45 researchers, software engineers and entrepreneurs in 2010, gave them 30 data sets and asked them what they could do in 30 days to develop prototype applications. That event became known as the first Health Datapalooza, recalled Bryan Sivak, chief technology officer of the Health and Human Services Department.
In June, the fifth annual Health Datapalooza was held in a convention center in Washington, and there were 2,000 attendees. Today, there are 1,700 different data sets on HealthData.gov.
Stride Health, according to Mr. Sivak, is one of the new breed of of data-driven innovators in health care, typically outsiders to the industry who bring a fresh perspective. "They are beginning to use data in incredibly interesting ways that will benefit a whole lot of people," Mr. Sivak said.
Stride Health's investors include New Enterprise Associates, Kleiner Perkins Caufield & Byers, DCM, the Mayo Clinic and Rock Health, an incubator and investor in health start-ups. Stride Health's business model is being a broker, collecting commissions on sales of recommended insurance policies. "I never thought I'd be selling health insurance," said Mr. Lang, a graduate of Stanford University.
No one at Stride Health, Mr. Lang insists, knows what the commission is on a policy before a sale, ensuring that recommendations are not skewed to suggest more profitable offerings.
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August 22, 2013 Thursday
The Affordable Care Act and Part-Time Work
BYLINE: JARED BERNSTEIN
SECTION: BUSINESS; economy
LENGTH: 445 words
HIGHLIGHT: A model comparing the expected and actual rates of involuntary part-time work indicates that the health care law has not had a significant effect, an economist writes.
Jared Bernstein is a senior fellow at the Center on Budget and Policy Priorities in Washington and a former chief economist to Vice President Joseph R. Biden Jr.
Among the various attacks on the Affordable Care Act, one of the more coherent - a low bar, given what's out there - is that it is causing small employers to create part-time jobs so as to remain under the 50 full-time worker cutoff for the employer mandate. The problem for those who want to come at the law from that angle, however, is that though the incentive exists, the evidence does not.
As Paul Van de Water and I pointed out in Politico the other day, if employers were responding to the incentive the way the critics claim, we should see involuntary part-time work growing as a share of total jobs, as workers who want full-time jobs would be stuck with part-time ones. But both involuntary and overall part-time work are slowly declining as a share of all jobs.
Still, it is legitimate to ask whether the slow decline in the share of part-timers is occurring more slowly in this recovery because of the incentive to stay under 50 full-timers. So I built a simple statistical model of the relationship between the share of involuntary part-time work and the unemployment rate. I then ran the model through the first half of 2009, and predicted, using the actual unemployment rate, the shares of involuntary part-time work.
Involuntary Part-Time Work: Actual and Predicted
If the law were keeping more than the usual number of full-time workers stuck in part-time jobs, then the predicted trend would be significantly below the actual one. In fact, the two trends hug each other quite tightly, further evidence that part-time employment is much where we would expect it to be at this stage of recovery, given the high level and slow decline in the jobless rate.
At the end of the day, no one's saying the incentive does not exist or that it won't show up somewhere down the road in the data. But there are good reasons to believe it will be small, and it's not there yet.
Moreover, there's no question that the United States needs to reform what has been an unsustainably wasteful health care delivery system, which both costs more than in other countries and covers a smaller share of the population. The Affordable Care Act already appears to be moving us in the right direction with few side effects. The smart move now is to implement it and keep a close watch out for consequences, both intended and otherwise.
The New Economics of Part-Time Employment, Continued
A Surge in Part-Time Workers
The New Economics of Part-Time Employment
What Job-Sharing Brings
Breaking Out of a Cramped Economic Policy Debate
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The New York Times
January 18, 2017 Wednesday 00:00 EST
Choice for Health Secretary Is Vague on Replacing Affordable Care Act
BYLINE: ROBERT PEAR and THOMAS KAPLAN
SECTION: US; politics
LENGTH: 1260 words
HIGHLIGHT: At a Senate hearing, Representative Tom Price set lofty goals for replacing the health law but did not say how he would achieve them.
WASHINGTON - Representative Tom Price, the man President-elect Donald J. Trump has chosen to lead the Department of Health and Human Services, promised on Wednesday to make sure people do not "fall through the cracks" if the Affordable Care Act is repealed, and set a goal to increase the number of people with health insurance.
But at a hearing before the Senate Health, Education, Labor and Pensions Committee, Mr. Price provided only vague reassurance to members of both parties who pressed him for specific policies.
Republicans concluded he was well qualified; Democrats were not satisfied.
"Just days ago, President-elect Trump promised, quote, 'insurance for everybody,'" said Senator Patty Murray of Washington, the senior Democrat on the committee. "But Congressman Price, your own proposals would cause millions of people to lose coverage, force many people to pay more for their care, and leave people with pre-existing conditions vulnerable to insurance companies' rejecting them or charging them more."
In four hours of testimony, Mr. Price, an orthopedic surgeon from the affluent northern suburbs of Atlanta, set lofty goals for a plan to replace the Affordable Care Act, President Obama's signature domestic achievement, but did not say how he would achieve them.
Mr. Price, 62, also denied impropriety in his trading of stocks in health care and pharmaceutical companies, saying he had left many details to his broker. The Wall Street Journal reported last month that he had traded more than $300,000 worth of shares while promoting legislation that could have affected the companies he owned stock in.
Senator Al Franken, Democrat of Minnesota, said one investment looked like a "sweetheart" deal. But Mr. Price said, "I had no access to nonpublic information."
Like several other candidates for top jobs in the Trump administration, Mr. Price put a little distance between himself and the president-elect on several issues.
Mr. Trump said last week that drug companies were "getting away with murder" and that Medicare should negotiate with drugmakers to secure lower prices, a position long championed by Democrats and fiercely opposed by Republicans.
Asked if he would press Congress to authorize such negotiations, Mr. Price did not give a definitive answer. "I think we need to find solutions to the challenges of folks' gaining access to needed medication," he said.
He added that, if confirmed, he would try to give states more freedom and flexibility under Medicaid, the federal-state program that provides coverage for more than 70 million low-income people. In response to questions, he said states should be allowed to require certain able-bodied adults without children to work, seek work or participate in job training as a condition of receiving Medicaid. Some Republican governors want to impose such requirements, but the Obama administration has turned down their proposals.
Mr. Price praised Indiana's program to expand Medicaid eligibility under the Affordable Care Act with conservative policies that state officials say promote "personal responsibility."
"States know best" how to care for their Medicaid beneficiaries, he said, adding, "What Indiana has done is really a best practice, I think, for many other states to follow."
Mr. Trump has not said much about the future of Medicaid in the 31 states that have expanded eligibility, with large amounts of federal money.
Democratic senators were often frustrated in their efforts to get Mr. Price to say whether he supported the coverage requirements and insurance mandates in the Affordable Care Act.
In a typical response, he said that patients should have "access to the kind of coverage that they want," rather than having it dictated to them by the government.
Senator Christopher S. Murphy, Democrat of Connecticut, said that Mr. Price appeared to support the coverage and protections provided by the Affordable Care Act, but that "we don't get any specifics as to how that's going to occur" if the law is repealed.
Without mandating coverage of specific benefits, Mr. Price said, the Trump administration could "make certain that individuals had the care and the kind of coverage that they needed for whatever diagnosis would befall them."
He said the administration could put in place "a different construct" that "would allow for every single person to gain access to the coverage that they want and have nobody fall through the cracks."
He did not say how the Trump team would guarantee such protection.
Mr. Trump has expressed support for a provision of the 2010 health law under which insurers must allow children to stay on their parents' policies until the age of 26. This is "baked into the insurance programs that are out there right now," Mr. Price said.
"I think that the insurance industry has included individuals up to age 26 on their parents' policies virtually across the board," he said, "and I don't see any reason that that would change."
Democrats were skeptical. Senator Maggie Hassan of New Hampshire said there was no guarantee that such protections would continue in the absence of federal requirements. Insurance companies did not routinely cover drug abuse treatment in the past and might not do so in the future without a requirement, she said.
The Congressional Budget Office said Tuesday that the number of uninsured Americans could increase by 18 million in one year if Congress repealed major parts of the health care law while leaving others. Mr. Price tried on Wednesday to allay fears of disruption.
"I think there's been a lot of talk about individuals losing health coverage," Mr. Price said. "That is not our goal, nor is it our desire, nor is it our plan."
"One of the important things that we need to convey to the American people is that nobody's interested in pulling the rug out from under anybody," he said. "We believe that it's absolutely imperative that individuals that have health coverage be able to keep health coverage and move, hopefully, to greater choices and opportunities for them to gain the kind of coverage that they want for themselves and for their families."
Mr. Price said he would "absolutely" consider administrative action to stabilize the market for insurers, which are supposed to submit proposals for 2018 coverage in April. Insurers say it will be nearly impossible to calculate premiums if they have no idea what will replace the health care law.
Mr. Price championed "medical innovation" as an essential ingredient of high-quality care but criticized the Center for Medicare and Medicaid Innovation, which was created by the health law to test new ways of paying doctors, hospitals and other providers.
He said that the agency had great promise, but that too often, its experiments were compulsory for doctors and nearly nationwide in scope. He said he "adamantly opposed the mandatory nature" of some payment models, like one for joint replacement surgery and one for expensive drugs administered in doctors' offices.
Mr. Price said he would not object if Medicare tested payment methods with small pilot projects that could expand if successful.
The health committee will not vote on Mr. Price's nomination. Another hearing has been scheduled for Tuesday by the Senate Finance Committee, which will vote on whether to recommend confirmation. The committees share authority over issues for which the Health and Human Services Department is responsible.
PHOTO: Representative Tom Price of Georgia, the candidate for health and human services secretary, at his hearing on Wednesday. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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September 24, 2013 Tuesday
How to Gut Obamacare
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 826 words
HIGHLIGHT: Even they fail to strip out funding, Congressional foes of the Affordable Care Act could further their aims by shutting down the government or putting off the individual mandate, two studies indicate.
If House Republicans want to fray the Affordable Care Act on the eve of its implementation, defunding it won't work. They'd be better off stripping or delaying the individual mandate.
That's the conclusion of two recent studies that speak to one of the many moving pieces in this fall's vicious budget debate.
House Republicans last week passed a bill that would keep on financing the federal government, but not the Affordable Care Act. Specifically, the bill orders: "Notwithstanding any other provision of law, no federal funds shall be made available to carry out any provisions of the Patient Protection and Affordable Care Act" or a related law. It also retracts the "entitlement to benefits" - that is, the Medicaid expansion - in the law.
If the Senate, with a Democratic majority, passed the bill from the Republican-controlled House as is, the law would be shot. There would be no federal money for the state exchanges, or to cover low-income adults in Medicaid. But there's no way the Senate would pass the House bill. Even if it did, President Obama has vowed a veto.
Rather, any defunding would be temporary, because of a government shutdown. On the day the exchanges were due to open, much of the federal government would go offline, including a big portion of the Health and Human Services Department that is running the coverage expansion. But legislative inaction cannot gut Obamacare in the way that legislative action could. During a shutdown, implementation would "substantially" continue.
That's according to a Congressional Research Service report prepared for Senator Tom Coburn, an Oklahoma Republican. In no small part, the reason is that much of the Affordable Care Act's financing comes from mandatory spending, rather than discretionary spending, and a continuing resolution concerns only the latter. Moreover, some of the law's money comes from multiyear or "no-year" discretionary funds that do not get wrapped up in the continuing-resolution process either. The Health and Human Services Department says its reform implementation fund would not get touched by a lapse in appropriations.
That is not to say that a shutdown, especially a long one, would not throw a wrench in health care reform or other programs financed with mandatory money. The Congressional Research Service report, for instance, looks at what happened to Medicare during the shutdowns in 1995 and 1996. It continued to pay doctors and hospitals. But its financing for its claims-processing vendors came from the discretionary budget. During the shutdown, those vendors kept working with only the expectation that they would get paid later. And during a long shutdown, "claims payments might cease as vendors ran out of cash to cover their operating costs," the research service report says.
Temporary defunding probably would not do much. But Congress could substantially mar the law by stripping or delaying the tax penalties on Americans who decline to buy insurance - the so-called "individual mandate." And it is one tactic that Speaker John A. Boehner of Ohio is mulling.
A new Urban Institute study explains why. Using Congressional Budget Office figures, it shows that delaying the individual mandate for a year would reduce coverage by about 11 million people in 2014. That would save the government some money. However, the effect on the health insurance marketplace might be profound. Many young and healthy people would decline to buy insurance coverage, with no penalty. The pool of the insured would be relatively sicker. Insurers would be forced to increase rates, as the healthy would do less to cross-subsidize the ill. Premiums would shoot up.
Here's the institute on the multibillion-dollar problems that might create:
There is significant risk that low exchange enrollment in the first year due to the lack of a mandate could begin an adverse selection cycle which would make it difficult to establish viable risk pools in the exchange in future years. While the Urban Institute estimated that premiums without the mandate could be up to 24 percent higher than with the mandate, that analysis assumed fully effective risk adjustment across the exchange and nonexchange markets. Less effective risk adjustment could lead to even higher premiums in the exchange without the mandate and could dissuade insurers from participating in the new markets; this could then further dissuade healthier individuals with current nongroup coverage from entering the exchanges, exacerbating the effect in the following years.
In short, even a one-year delay in the mandate might cause cost problems throughout the insurance market - and from the perspective of the law's supporters, that might be a lot worse than hassles related to a temporary shutdown.
Health Coverage Worthy of a Senator
Who Abandoned the Health Insurance Credit
The Path to Complexity on the Health Care Act
50 Years After the House Vote for the Kennedy Tax Cut
Nevada's Jobless Feel the Sequester
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December 4, 2013 Wednesday
Poll Finds Young People Souring on Health Law and Obama
BYLINE: Sheryl Gay Stolberg
SECTION: US
LENGTH: 498 words
HIGHLIGHT: A majority of 18- to 29-year-olds disapprove of the Affordable Care Act, and fewer than a third of those who are uninsured are likely to sign up for coverage, according to a new poll by Harvard University’s Institute of Politics.
WASHINGTON - A majority of 18- to 29-year-olds - a constituency crucial to the success of President Obama's health overhaul - disapprove of the law, and fewer than a third of those who are uninsured are likely to sign up for coverage, according to a new poll by Harvard University's Institute of Politics.
The survey, released Wednesday, also found a stark drop in Mr. Obama's approval ratings among those so-called millennial voters, who have long been his most ardent supporters.
Just 41 percent now approve of the president, down from 52 percent in October 2012, a finding that puts young voters more in keeping with the general population. The younger half of the cohort, those 18 to 24, tilts increasingly conservative; the poll found that 52 percent of this group - many of them too young to have voted for Mr. Obama when he first ran in 2008 - would vote to recall him from office if they could.
"For the better part of the last four or five years, young people have been the outliers," John Della Volpe, the institute's polling director, said during a conference call with reporters. He attributed the drop to high expectations, "not just for the president but for Washington and adults in general, that have been unmet."
The findings bode ill not just for the president but also for Congressional Democrats, who must run for re-election in 2014 facing questions about the Affordable Care Act. They also present problems for the health law itself.
Enrolling young people, who tend to be healthier and need less medical care, is critical to keeping premiums down. But just 29 percent of those who are uninsured said they would sign up for coverage if eligible to do so. (The law allows young people to stay on their parents' plans until age 26.)
Trey Grayson, the institute's director, said the views of young people, who have grown up expecting websites to work flawlessly, may be colored by the troubled roll-out of HealthCare.gov, the online insurance exchange. And Mr. Grayson said young people might also be disenchanted with the notion that their participation is required to keep costs down for their elders.
Whatever the reason, the poll found "there are very few aspects of the health initiative" that young voters approve of, Mr. Della Volpe said. Attitudes were relatively unchanged regardless of whether it law was referred to as Obamacare or by its proper name, the Affordable Care Act.
A solid majority, 56 percent, disapproved of the law when it was called the Affordable Care Act. Just 17 percent said the measure would improve the quality of health care; 78 percent said quality would either stay the same or get worse. Half said the law would increase costs, while 46 percent said costs would decrease or stay the same.
The survey, of 2,089 18- to 29-year-olds, was conducted between Oct. 30 and Nov. 11 and had a margin of error of plus or minus two percentage points. It is the latest in a series of two dozen polls that Harvard has conducted of young voters since 2000.
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The New York Times
January 5, 2014 Sunday
Late Edition - Final
Health Care in America
SECTION: Section SR; Column 0; Editorial Desk; LETTERS; Pg. 10
LENGTH: 969 words
Michael Moore called Obamacare both 'awful' and a 'godsend.' Readers offer their opinions.
To the Editor:
Re ''The Obamacare We Deserve'' (Op-Ed, Jan. 1):
Michael Moore is correct -- Americans deserve a single-payer system, and the Affordable Care Act is a poor substitute. But Mr. Moore does not mention that, for all its faults, the law would be working much better but for the unrelenting effort by Republicans to sabotage it by various means, such as propagating outright lies intended to confuse the public (''death panels''), refusing in numerous states either to extend Medicaid benefits or to establish state insurance exchanges, and proactively urging people not to obtain insurance under the law.
Contrast the reaction of Republicans to the health care law with that of Democrats to Medicare, Part D. That prescription drug benefit, enacted by a Republican Congress with the help of parliamentary legerdemain, had terrible flaws, most notably the so-called doughnut hole (partly alleviated by the new health care law) and the provision prohibiting Medicare from negotiating prices with the pharmaceutical industry. Nevertheless, once Part D became law, Democrats never tried to defund or undermine it; to the contrary, they tried to make it work.
I doubt that there has ever been a more cynical political action than the effort by Republicans to destroy a law based on ideas that they themselves conceived and first put into practice, thus depriving millions of Americans of the opportunity to receive quality health care. If they succeed, we will continue to have one of the most expensive and least effective health care systems in the developed world.
PETER HANAUER Berkeley, Calif., Jan. 2, 2014
To the Editor:
I read Michael Moore's Op-Ed essay as I heard news of the death from cancer of Benjamin Curtis, the young guitarist with School of Seven Bells. He needed to have fund-raisers to pay medical bills while fighting to live.
How many times each week do I read of similar sagas, of some child or young person whose parents, friends or others are holding a fund-raiser for medical bills? They usually have insurance, but it's not enough to cover the horrendous expense.
What kind of a society have we created in which obtaining adequate medical care depends on the charity of well-wishers instead of the strong voice of an enlightened electorate?
JOHN LINGENFELDER Plano, Tex., Jan. 1, 2014
To the Editor:
Michael Moore has never minced words. He doesn't like Obamacare because he knows how much better it could be. But to his credit, he also recognizes it as a plus, on balance. Among other things, it makes coverage affordable for many who could not afford insurance before and prohibits insurers from denying coverage to people with pre-existing conditions. Although he doesn't mention them, the law also has provisions to improve quality and contain costs.
Nonetheless, the Affordable Care Act could certainly be better. As it is carried out and people begin to experience both its benefits and its imperfections, citizens can take action to make it better. Mr. Moore mentions two ideas already being promoted: a plan in Massachusetts to allow the state to operate a public option in competition with the private plans offered through its exchange, and Vermont's bold single-payer plan. Undoubtedly, there will be more, and some will succeed. Taken together, they will represent contemporary instances of American pragmatism, the continual search for better solutions to life's problems.
STEPHEN M. DAVIDSON Brookline, Mass., Jan. 1, 2014
The writer, a professor at the Boston University School of Management, is the author of ''A New Era in U.S. Health Care: Critical Next Steps Under the Affordable Care Act.''
To the Editor:
Michael Moore is surely correct when he boldly asserts that in its present form ''Obamacare is awful.'' The Affordable Care Act is the classic example of a horse designed by a committee. Unfortunately for the rest of us, the committee co-leaders were the pharmaceutical industry and the insurance industry, dictating terms to their hired hands in Congress.
Despite Mr. Moore's optimistic call for further action, it is far from certain that our present monstrosity can be turned back into a horse that can carry the burden of real, affordable health care for all Americans.
RON BONN San Diego, Jan. 1, 2014
To the Editor:
I agree with Michael Moore that the Affordable Care Act is seriously flawed. A fraught question is whether, as its shortcomings become more evident, this will make a transition to the far more desirable single-payer health care system more or less likely. I fear less likely, at least in the short term.
The evidence that a single-payer system would be superior to either the pre- or post-Obamacare situations is clear, if we consider the experiences of the rest of the developed world. Time and again, in international comparisons of health care outcomes, the United States ranks dismally low, despite the fact that our system ranks first in terms of per capita cost.
Of course, America prides itself on being an ''exceptional'' nation. In this case, we have an exceptionally inefficient and ineffective health care system.
RUSS WEISS West Windsor, N.J., Jan. 1, 2014
To the Editor:
Over the years President Obama has indicated that he would support single payer if it were politically possible. Given this country's distrust of government, reliance on the free market and lack of political will then and now, he pragmatically knew from the outset that he did not have the votes in Washington to achieve it. It remains remarkable, however, that for all the technical snags and shortcomings of the Affordable Care Act, America got anything resembling a collective plan after a century of efforts that were largely unsuccessful.
PETER BARKLEY Cambridge, Mass., Jan. 1, 2014
URL: http://www.nytimes.com/2014/01/05/opinion/sunday/health-care-in-america.html
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November 14, 2013 Thursday
Wisconsin Governor Seeks to Extend Medicaid for Some Low-Income Residents
BYLINE: Steven Yaccino
SECTION: US
LENGTH: 512 words
HIGHLIGHT: “We want to make sure nobody falls through the cracks,” said Gov. Scott Walker, citing the troubled rollout of the new federal health care law.
Blaming an "abysmal" rollout of the new federal insurance market, Gov. Scott Walker of Wisconsin said on Thursday that he would ask the Legislature to allow thousands of low-income residents to remain in the state's Medicaid program until April 1 - a three-month extension.
In a news conference, Mr. Walker, a Republican, said he would ask the Legislature, which is Republican-controlled, to return in early December to vote on his proposal. Under current state law, about 77,000 Wisconsin residents would be removed from the state's Medicaid rolls on Jan. 1 and required to obtain insurance in the subsidized online federal marketplace created by President Obama's Affordable Care Act.
"The whole reason we're here today is because the federal government couldn't get its act together," Mr. Walker said, referring to the problem-plagued federal exchange, healthcare.gov.
The shifting of state Medicaid recipients onto the federal exchange was part of the budget plan pushed by Mr. Walker and enacted by the Legislature this year. The state funds saved by that shift were then to be used to pay for coverage for some very low-income adults.
In his news conference, Mr. Walker said the addition of the very low-income adults into the state program would also be delayed for three months.
"We're talking about real people's lives," Mr. Walker said. "I'm not going to let the failures of the federal government bring down people who are caught in between systems that just aren't working right now."
The announcement by Mr. Walker, who is viewed as a potential 2016 presidential contender, came just hours after President Obama announced a year's extension for insurance companies to keep people on health care plans that they were set to lose as a result of the Affordable Care Act.
Like many Republican governors, Mr. Walker declined to set up a state-run health exchange or accept federal dollars for expanding Medicaid expansion as was allowed under the Affordable Care Act.
According to numbers released by the federal Department of Health and Human Services on Wednesday, 877 people in Wisconsin signed up for health care plans during the first month of the marketplace.
On Tuesday, Mr. Walker also proposed extending a state insurance program for people with pre-existing conditions until April 1. And he called on the Obama administration to permit federal subsidies to be used to pay for qualified plans that are not offered on the federal exchange.
Mr. Walker expressed confidence that his proposals would get sufficient support in the Legislature.
"I think just about everyone out there acknowledges that the rollout of Obamacare has not been as effective as originally proposed," he said. "And that because of that we want to make sure nobody falls through the cracks."
Health Care Coverage Business Is Bustling at New York City Hospital
Health Exchange: A One-Month Checkup
People Who Buy Own Health Policies Face Big Changes
Awareness Grows of Online Insurance Exchanges, and Their Problems, Survey Finds
Readers Ask How Insurance Subsidies Are Calculated for Students
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August 2, 2013 Friday
Who Abandoned the Health Insurance Credit
BYLINE: PHILLIP SWAGEL
SECTION: BUSINESS; economy
LENGTH: 545 words
HIGHLIGHT: It wasn’t Congressional Republicans who moved the health care debate away from a proposal to extend coverage through a tax credit, an economist writes.
Phillip Swagel is a professor at the School of Public Policy at the University of Maryland and was assistant secretary for economic policy at the Treasury Department from 2006 to 2009.
Bruce Bartlett's post this week provided the fascinating history of the tax benefit for employer-provided health insurance. His account of the recent political economy of health care tax policy, however, left out some developments that put the issue in rather a different perspective.
As Mr. Bartlett noted, Senator John McCain in his presidential campaign proposed to change the tax exclusion into a flat credit of $5,000. People who purchase their own health insurance do not receive the tax benefit for employer-provided coverage but would have benefited from the McCain proposal. The credit would have been refundable, providing a tax benefit for health insurance to the millions of low-income families who do not have a positive income tax liability and thus likewise do not benefit from the deduction for employer-provided insurance.
The tax credit would have made an important contribution to addressing the problem of the uninsured that is a central focus of the Affordable Care Act. A health care "mandate" is only as meaningful as the penalty for not obeying the government's dictate. A $5,000 refundable credit would have been economically similar to a mandate, since those not purchasing health insurance effectively would be giving up $5,000 for their household. By contrast, the penalty under the Affordable Care Act for not taking up the mandate is as little as $95 a person in 2014, rising to $695 a person or $2,085 for a family in 2016. With the government writing $5,000 checks to people who buy health insurance, one might have expected insurance companies to devise policies that cost exactly the amount of the credit and then to make concerted efforts to enroll people. There would have been little need for Kathleen Sebelius, the secretary of health and human services, to solicit private donations for outreach to the uninsured.
Mr. Bartlett's post explains the merits of the McCain health insurance tax proposal. Not mentioned in the post, however, is that attacks on the McCain proposals featured prominently in the 2008 Obama campaign. These attacks were ironic inasmuch as the McCain tax proposal had actually been put forward by economists advising the Obama campaign. And then even more ironic since the Affordable Care Act includes a tax on health insurance despite President Obama's campaign stand. Also worth noting is that the tax on high-cost insurance plans under the act maintains the link between spending and tax benefits and thus does less to improve incentives than the McCain flat tax credit.
It is striking that Mr. Bartlett's post attributes to Republicans a "partisan political decision to abandon the McCain plan." Partisan political decisions did figure prominently in moving the health care debate away from the tax proposal extolled in the post. It is puzzling, however, for the critical focus here to be on Congressional Republicans.
The Path to Complexity on the Health Care Act
Health Coverage Worthy of a Senator
Dynamic Scoring Once Again
A Spurned Offer on Corporate Taxes
The Question of Taxing Employer-Provided Health Insurance
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January 15, 2017 Sunday 00:00 EST
Trump Promises 'Insurance for Everybody' as Health Law Replacement
BYLINE: MICHAEL D. SHEAR
SECTION: US; politics
LENGTH: 589 words
HIGHLIGHT: The president-elect said he was nearly ready to unveil his proposal, though he offered no details about how it would work or how much it would cost.
WASHINGTON - President-elect Donald J. Trump said this weekend that he was nearly ready to unveil a plan to replace President Obama's Affordable Care Act with "insurance for everybody."
Mr. Trump, in an interview Saturday evening with The Washington Post, said that health care offered under his plan would come "in a much simplified form - much less expensive and much better."
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."
In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."
He also offered no explanation of how he would persuade Congress to pass his plan, though he indicated that it would have the backing of the House speaker, Paul D. Ryan of Wisconsin, and the Senate majority leader, Mitch McConnell of Kentucky. Mr. Trump said only that "I won't tell you how, but we will get approval."
He seemed to refer to his recent Twitter posts that helped persuade House Republicans to back away from a proposal to gut an ethics office. "You see what's happened in the House in recent weeks," he said.
Top aides to Mr. Trump declined to provide more information about the president-elect's plans. In an interview last week with The New York Times, Mr. Trump said he wanted Congress to repeal the Affordable Care Act and replace it "very quickly or simultaneously, very shortly thereafter."
The president-elect told The Post that his plan would be unveiled soon after the Senate confirmed Representative Tom Price, Republican of Georgia, to be the secretary of health and human services.
Achieving the promise of "insurance for everybody" has been a goal of health care policy experts for decades, but the political and financial realities have proved problematic. Government-provided health insurance, known as a single-payer plan, has found little political support in Washington. And market-based solutions, like the Affordable Care Act, have proved difficult to carry out.
Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives. And liberals who support Mr. Obama's health care plan - which provides coverage to 20 million people - may be wary of the fine print of a program that claims to cover everybody.
Mr. Trump said specifically on Saturday that "I don't want single-payer." He told The Post that he would force drug manufacturers to negotiate better prices with Medicaid and Medicare, the government-run health programs.
Asked how he would force the drug companies to do that, he noted the public pressure that he had exerted on other companies, mentioning his Twitter posts criticizing cost overruns for Lockheed Martin's F-35 fighter jet.
Last week, the House and the Senate began the process of repealing Mr. Obama's health care law by approving parliamentary language that allows them to proceed without the threat of a filibuster by Democrats.
But Republicans have expressed anxiety about the demands from Mr. Trump and others for a quick replacement of the law. Many believe that will require a very complex plan that could be tricky to develop and push through Congress.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
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December 2, 2016 Friday 00:00 EST
U.S. Health Spending in 2015 Averaged Nearly $10,000 Per Person
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 723 words
HIGHLIGHT: Federal spending on health care increased by 21 percent over the past two years as millions of Americans gained coverage, the government reported.
WASHINGTON - Total spending on health care in the United States increased last year at the fastest rate since the 2008 recession, reaching $3.2 trillion, or an average of nearly $10,000 a person, the Department of Health and Human Services reported on Friday.
The growth coincided with continuing increases in the number of Americans with insurance coverage, through private health plans or Medicaid.
Federal spending on health care has increased by 21 percent over the past two years, as millions of Americans gained coverage through the Affordable Care Act, the department said in its annual report on health spending.
The increase in federal spending was driven mainly by the expansion of Medicaid eligibility and enrollment, according to the report, published online in the journal Health Affairs.
Under the Affordable Care Act, the federal government has been paying the full cost of Medicaid coverage for newly eligible beneficiaries. Thirty-one states have chosen to expand eligibility.
Over all, the government said, health spending accounted for 17.8 percent of the nation's economy in 2015, up from 17.4 percent in 2014.
Total health spending rose 5.8 percent last year, and spending per person increased 5 percent. The Obama administration said this growth was "below the rates of most years prior to passage of the Affordable Care Act."
Anne B. Martin, an economist who was the principal author of the report, said the federal government became the largest source of health spending last year, accounting for 29 percent of the total - more than households, private businesses or state and local governments. That stems not only from rising coverage through the health law but also an aging population, which is expanding Medicare.
The health law was always expected to fuel an increase in health spending, but the law has cost less than originally projected by the Congressional Budget Office, in part because the number of people signing up for subsidized coverage through online insurance exchanges was lower than expected.
Growth in total national health spending was exceptionally low for five years, from 2009 through 2013, in part because of lingering effects of the recession, officials said. The White House also asserted that the health law had slowed health spending, by cutting the growth of Medicare payments to many health care providers and by encouraging them to become more efficient.
"Over the last 55 years, the largest increases in health spending's share of the economy have typically occurred around periods of economic recession," Ms. Martin said. "The 2014 and 2015 increases occurred more than five years after the last recession ended. But they coincided with 9.7 million individuals gaining private health insurance coverage and 10.3 million more people enrolling in Medicaid."
Rapid increases in retail spending on prescription drugs also contributed to the growth of national health spending, officials said.
The report noted "strong growth in new specialty medications such as those used to treat hepatitis C, cancer, autoimmune diseases and multiple sclerosis, as well as in more traditional brand-name medications such as those used to treat diabetes."
In 2015, the report said, prices for existing brand-name drugs increased at a double-digit rate for the fourth consecutive year. An increase in the number of new drugs approved for use was also a factor.
"In 2015," the government said, "45 new drugs were approved, more than in any one year over the past decade."
Retail sending on prescription drugs grew 9 percent last year - more than any other category of health care goods and services - and reached $324.6 billion, representing 10 percent of all health spending, the government said.
Those figures understate drug spending, officials said, because they generally do not include spending on drugs administered in doctor's offices, hospitals and nursing homes.
In the past two years, the report said, 20 million people either gained private health insurance coverage or enrolled in Medicaid, primarily as a result of the Affordable Care Act. The share of the population with health coverage increased to 90.9 percent in 2015, from 86 percent in 2013, before the law's major coverage provisions took effect.
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February 19, 2014 Wednesday
Late Edition - Final
Delay of the Health Law's Employer Mandate
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 18
LENGTH: 292 words
To the Editor:
Re ''Further Delays for Employers in Health Law'' (front page, Feb. 11):
As the owner of a company that employs nearly 100 people, I was relieved to learn that the employer mandate of the Affordable Care Act would be delayed by a year for employers like me. The troubling aspect of the mandate is not just that it imposes a financial and administrative burden on small business, but, more important, the methodology used to determine the requirements.
Since the mandate is based solely on the number of employees, and not revenue or profitability, companies such as mine that provide many jobs but produce lower margins are squeezed even tighter, while companies that may be more financially capable of providing additional benefits are excused, because they employ very few.
I applaud the legislative intent of the Affordable Care Act to increase access to health care. But if the administration also expects to reduce the level of unemployment, the employer mandate as currently written does not advance that goal. Rather, it provides an incentive for small companies to restrict job growth.
YOEL BORGENICHT President, King Rose Construction New York, Feb. 12, 2014
To the Editor:
The political calculation behind the Obama administration's decision to yet again delay aspects of the employer health insurance mandate is misguided. Employers who despise the Affordable Care Act will not be placated by a year's delay. This is not a maneuver that will win their votes.
However, ordinary citizens who stand to gain from the law need to receive its benefits now if they are to have a reason to vote, and to vote Democratic, this November.
RICHARD LACHMANN Albany, Feb. 11, 2014
The writer is a professor of sociology at the University at Albany, SUNY.
URL: http://www.nytimes.com/2014/02/19/opinion/delay-of-the-health-laws-employer-mandate.html
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November 14, 2016 Monday 00:00 EST
Politics Aside, We Know How to Fix Obamacare;
The New Health Care
BYLINE: AUSTIN FRAKT
SECTION: UPSHOT
LENGTH: 1281 words
HIGHLIGHT: The problems afflicting the Affordable Care markets are similar to those once faced by Medicare Advantage.
President Obama's Affordable Care Act marketplaces were supposed to give consumers choices of health plans from insurers that compete to keep premiums down. But fewer insurers are participating, and premiums are increasing sharply.
Fixing this problem will obviously be politically difficult with a Republican-controlled Congress that has vowed to "repeal and replace." President-elect Donald J. Trump has also said he wants to get rid of the Affordable Care Act, although he amended that recently by saying he'd like to keep some elements. Replacing the law, without a Senate supermajority, would also be politically difficult.
From a policy standpoint, however, some solutions to problems facing the marketplaces are ones that Republicans have endorsed before: for Medicare.
The number of insurers participating in the Obamacare marketplaces is falling. This year, 182 counties had only one insurer offering plans. Next year, that will be true of nearly 1,000 counties, or almost one-third of the total. An average marketplace will offer 17 fewer plans in this fall's open-enrollment period than last year's. Fewer choices make it harder for consumers to find plans that meet their needs, like including doctors and hospitals they prefer and covering the drugs they take.
Shrinking choice isn't the only problem facing the marketplaces. On average, the most popular type of plan will cost 22 percent more next year than this year. However, in some regions, premium increases are much larger; residents of Phoenix will see a 145 percent rise. (In some regions, increases are low; Columbus, Ohio, is facing only a 3 percent increase.)
Insurers' exits and rising premiums are related. Both are happening because the number of enrollees and their health care needs are not what insurers expected. One piece of evidence that this occurred is that the Obamacare marketplace plans attracted more older people than the administration's initial projection. Another factor: In states that did not expand their Medicaid programs, some sicker, higher-cost consumers that would otherwise be Medicaid-eligible are in marketplace plans.
If insurers attract too few consumers with little or modest health needs and, instead, attract a larger proportion of sicker ones, health care costs outstrip premium revenue. In the worst case, an insurance company throws up its hands and exits the market. Some insurers that have left Obamacare markets stated they did so because they could not earn enough money to keep up with costs.
Increasing premiums might close the revenue-cost gap. However, premium increases can further discourage consumers, particularly healthier ones, from enrolling, worsening the problem.
As competition decreases, the remaining insurers have greater market power to increase premiums. States with the fewest insurers have the largest premium increases while those with more insurers have more modest premium growth. These facts are consistent with findings from both government and non-government organizations.
A study done in part by Leemore Dafny, a health economist now with the Harvard Business School, also illuminates the competition-premium connection. She and co-authors found that premiums in the first year of the marketplaces were 5.4 percent higher just because one national insurer opted out. Another study, published in Health Affairs, found that premiums fall by 3.5 percent with the addition of another insurer.
"Marketplaces will only succeed if enough insurers participate, and many are running away from what they perceive as a high-risk, low-reward market opportunity," she said.
All of this - insurer withdrawals and sharply escalating premiums - was avoidable and is fixable. We know how to draw insurers into markets, keep them there, and limit premium growth. We can do so by subsidizing plans more and by limiting their risk of loss. We've done both before.
In the early 2000s, Medicare+Choice - then the name of what is now the Medicare Advantage program, which offers private plan alternatives to traditional Medicare - was struggling. The proportion of Medicare beneficiaries with access to a Medicare+Choice plan declined from 72 percent in 1999 to 61 percent in 2002. The number of plans offered dropped 50 percent, and enrollment dropped 21 percent. Insurance industry representatives said that the problem was that government subsidy payments to plans were not keeping up with costs.
After payments to plans drastically increased as part of the 2003 Medicare Modernization Act - passed by a Republican Congress and signed by President George W. Bush - insurers flooded the market. This was controversial. Members of Congress from both parties expressed concern that plans were overpaid, wasting taxpayer resources.
By 2007, every Medicare beneficiary had access to at least one plan. The market stabilized, so much so that even as payments to plans were cut by the Affordable Care Act, plan enrollment continued to grow. Today, about one in three Medicare beneficiaries is enrolled in a private plan - a record high. Increasing the subsidization of Obamacare plans might have the same effect - reducing costs to consumers and drawing more of them, and insurers, into the market.
The Medicare Modernization Act also established Medicare's prescription drug program, Part D, which offers another lesson. It's also run entirely through private plans. They're cushioned against large losses by a risk corridor program. This helps plans stay in the market if they miscalculated the mix of patients they'd attract, and it allows them to keep premiums lower than they might need to if they had to hedge against the full brunt of potential losses.
The Affordable Care Act included a risk corridor program for marketplace plans, too, but it expires at the end of this year. So does a reinsurance program that compensates insurers for unusually high-cost enrollees. Following the model of Part D and making the risk corridor program permanent, as well as the reinsurance program, could help stabilize the marketplaces.
There are other ways to shore up Obamacare. Including a public option in the marketplaces would increase competitive pressure. A public option means having the federal government offering insurance plans, providing an additional choice (or choices, if the government offers multiple plans). If plans included more doctors and hospitals in their networks, it might pull more expensive patients from private plans, reducing the risks.
Another idea is to require insurers to participate in broad regions, which would limit their ability to selectively work in more profitable ones and shun ones that are less so, like rural areas. This would be consistent with Medicare Part D, which requires insurers that offer stand-alone drug plans to do so in multistate regions.
Yet another approach is to increase the penalty for eschewing coverage, which for many people is cheaper than buying insurance. Here again, we could look to Medicare, which includes penalties - which grow the longer one waits - for failing to enroll in coverage for physician services or drugs.
There's one significant problem with all these ideas, of course: They'd need to pass the Republican Congress and be signed into law by Mr. Trump. Though the G.O.P. has endorsed some of the ideas before - for Medicare - it's a safe bet they won't do so for the Affordable Care Act.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
Austin Frakt is a health economist with several governmental and academic affiliations. He blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt.
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(The Caucus)
July 10, 2014 Thursday
Obama's FunnyorDie.com Video Nominated for Emmy
BYLINE: JADA F. SMITH
SECTION: US; politics
LENGTH: 157 words
HIGHLIGHT: The president engaged in a sometimes silly, sometimes awkward interview with Zach Galifianakis.
President Obama may have a future in Hollywood. The FunnyorDie.com video starring Mr. Obama and Zach Galifianakis was nominated for an Emmy on Thursday in the category of short-format live-action entertainment programs.
The "Between Two Ferns" interview that both promoted and, to the dismay of some critics, lampooned the Affordable Care Act, will be competing against programs like the "Super Bowl XLVIII Halftime Show," "Childrens Hospital," "Parks and Recreation" and "The Soup."
The 6-minute-30-second clip showed the commander in chief engaging in a sometimes silly, sometimes awkward approach to spreading the word about his signature health care law.
"Have you heard of the Affordable Care Act?" Mr. Obama asked "The Hangover" star.
"Oh yeah," Mr. Galifianakis said. "I heard about that. That's the thing that doesn't work. Why would you get the guy that created the Zune to make your website?"
The ceremony will air on NBC on Aug. 25.
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(Taking Note)
October 21, 2013 Monday
Some Republicans Change Course on Health Care
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 391 words
HIGHLIGHT: Jeb Bush thinks the G.O.P. should try coming up with an actual alternative to the Affordable Care Act.
Reince Priebus, the chairman of the Republican National Committee, never misses a chance to accuse President Obama of being a terrible leader. So it was inevitable that he would pronounce Mr. Obama's Rose Garden speech today about problems with the federal health insurance Web site a sign of a "fundamental breakdown in leadership."
But some Republicans are actually getting weary of their party's approach to the Affordable Care Act.
Jeb Bush, the former governor of Florida, continued his pre-Presidential campaign campaign by arguing that the G.O.P. made a huge mistake when it shut down the government in an attempt to dismantle the health law.
If they had shown some "self-restraint," he said in an interview with ABC that was broadcast on Sunday, the government shutdown would not have eclipsed media coverage of problems with the site.
He also said that Republicans should try coming up with a reform plan of their own instead of just complaining about Mr. Obama's ideas.
"I think the best way to repeal Obamacare is to have an alternative," Mr. Bush said. "We never hear the alternative. We could do this in a much lower cost with improved quality based on our principles, free market principle. And two, show how Obamacare, flawed to its core, doesn't work."
Senator Tom Coburn, the Oklahoma Republican, offered a similar analysis. "The fight on Obamacare, or the Affordable Care Act, took us off message," he said on NBC's "Meet the Press" on Sunday. "The large percentage of American public knows that Washington wastes money. They just don't have a clue of how bad it really is and so we lost the message there of what really needs to happen in Washington."
(That, he said, is deficit reduction.)
Meanwhile, in Texas, the state government is actually urging residents to obtain health insurance coverage through A.C.A. exchanges, and is shutting down a state-run high-risk insurance program - because the A.C.A. has rendered it unnecessary.
Texans will have to do that through the technologically paralyzed federal Web site, however, because Gov. Rick Perry was one of those Republican governors who refused to set up a state insurance exchange for purely ideological reasons.
Is the Health Care Fight Over?
The Insufficient Craziness Theory
Boehner's Last Stand
G.O.P. Helps Americans Like Government
A New Danger for Democrats: Boehner's Delegation
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(First Draft)
January 8, 2015 Thursday
House Passes Bill to Alter Health Law's Workweek Provision
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 121 words
HIGHLIGHT: The 114th Congress took up its first bill to impose changes to the Affordable Care Act on Thursday, with the House of Representatives passing legislation to expand the definition of a workweek to 40 hours, from 30.
The 114th Congress took up its first bill to impose changes to the Affordable Care Act on Thursday, with the House of Representatives passing legislation to expand the law's definition of a workweek to 40 hours, from 30.
The bill passed 252 to 172, with a dozen Democrats siding with Republicans to change the provision, which critics of the law say is responsible for reducing full-time employment. Businesses are required to provide health insurance coverage to full-time workers under the law, and some companies have reduced their workers' hours to avoid the requirement.
The Senate, now under Republican control, is also expected to vote on the legislation despite threats by the White House that President Obama will veto it.
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(Campaign Stops)
June 28, 2012 Thursday
Bending Toward Universal Health Care
BYLINE: THEDA SKOCPOL AND LAWRENCE R. JACOBS
SECTION: OPINION
LENGTH: 1055 words
HIGHLIGHT: The court ruling ensures the law's survival in the long run, even if partisan battles over particular regulations and expenditures continue for some time.
IN finding the Affordable Care Act constitutional, a narrow majority on the Supreme Court, led by Chief JusticeJohn G. Roberts Jr., has surprised almost everyone. The decision is a victory for the century-long struggle to ensure basic health coverage for virtually all Americans, and it sets the nation on a path toward more rational, cost-effective ways of delivering care. These will be the eventual outcomes - but months and years of fierce political battles lie ahead.
Although the court upheld the act,President Obama's signature achievement to date, there were important twists. The federal government cannot order all Americans to have or buy health insurance, though it can collect a tax from those who do not have coverage after 2014. The federal government can offer the 50 states money to expand Medicaid coverage to all of the poor and near-poor - but cannot punish states that refuse by fully withdrawing existing Medicaid funds.
The decision shifts the political terrain for both parties. Over the past four years, the Republican Party has given up its traditional commitment to use regulated markets to extend health insurance coverage to all. It was Democrats who passed a law with elements long favored by Republicans - a law that radicalized Tea Party Republicans have now sworn to obliterate.
The ruling does not make President Obama's tough re-election bid any easier. The health care law, as enacted in 2010, required everyone to buy insurance once it was affordable, but its authors avoided talking about Congress's power to tax. Now the Roberts opinion makes it impossible to avoid speaking about a tax penalty. Media and legal analysts will want to keep the debates over the individual mandate going, and economists will ask whether taxes will need to be raised to compel recalcitrant holdouts to buy coverage after 2014. Will Mr. Obama be trapped in an endless mandate-discussion loop and forced to expend even more political capital on the one really unpopular part of health reform?
Not necessarily. Mr. Obama can now claim the mantle of "constitutionality" for his health care law - and start talking about the parts that are popular with 60 to 80 percent of Americans. Democrats, indeed all supporters of health reform, can tag Republicans with wanting to repeal or block those popular features like the insurance rules that protect people from being denied coverage for pre-existing conditions; the new benefits for young adults and older people on Medicare; the promised extension of affordable coverage to more than 30 million more low-income and lower-middle-income families; and tax credits for small businesses.
For as long as political scientists have measured public opinion, we have known that Americans respond to abstract questions by opposing "big government" but evaluate particular government benefits and actions very differently. As long as opponents of health reform could ask "Is it constitutional?" the argument was on their terrain. Now the debate will swerve back toward the popular core of the act, if the White House and Congressional Democrats are savvy in how they talk about existing and future benefits. (Reform supporters can also truthfully point out that only 2 out of every 100 people will be affected by the mandate without enjoying subsidies to help them buy affordable coverage.)
Mitt Romney and his fellow Republican refuseniks are in a new bind. They cannot wield the club of nonconstitutionality anymore. And in the debates, how is Mr. Romney going to bash Mr. Obama for extending to all Americans the very same insurance regulations and affordable health coverage that Mr. Romney enacted as governor for the people of Massachusetts - who like the results very much? We predict that Mr. Obama will eat Mr. Romney's lunch.
Of course, it's possible that the European economic crisis will send the world economy into another recession; that Mr. Romney and the Republicans will sweep the presidency and both houses of Congress; and that the Republicans will gut financing for the act. Using simple-majority budget rules, they could slash Medicaid and trim or delay subsidies to help low-income families buy private insurance. But they would still not have the 60 votes they'd need in the Senate to actually repeal the act - and the Supreme Court has now left intact the new rules for insurance companies and state-level exchanges prominently included in the law.
Moreover, the Republicans would create a political mess for themselves if they tried to "defund Obamacare," as many conservative lawmakers have vowed. Insurers would still have to issue policies to all comers, sick or healthy - but they would not get millions of new paid customers using credits and subsidies to buy their products. The states, including those with Republican governors, would be left with millions of citizens needing health care, but much reduced funding to help them. Many insurance companies and health care providers, not to mention health care reformers and Democrats, would fight to restore financing.
The same kind of dynamics would play out for states that choose to opt out of the Medicaid expansion in the act. (The Supreme Court ruled on Thursday that states may do so without losing all of their federal Medicaid financing.) The law provides for 90 percent federal subsidies for expanded Medicaid coverage, and states will find it hard to turn down this offer. As more and more states move toward universal coverage and well-functioning insurance exchanges, states that opt out will have trouble attracting businesses and health care professionals and lose out to other states in economic development.
In short, the historic court ruling ensures the law's survival in the long run, even if partisan battles over particular regulations and expenditures continue for some time. The arc of history now bends toward health care for all - and greater efficiency in the system as a whole. Mr. Obama and the Democrats may have to talk about health care more than they had planned going into November. But in the months and years ahead, the political challenges for Mr. Romney and the Republicans are even greater.
Seven Consequences of the Health Care Ruling
Could Defeat in Court Help Obama Win?
Will Time Heal Health Care Wounds?
The Liberal Embrace of Judicial Restraint
Our Imbecilic Constitution
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(You're the Boss)
December 6, 2013 Friday
My Health Insurance Was Canceled
BYLINE: MELINDA F. EMERSON
SECTION: BUSINESS; smallbusiness
LENGTH: 516 words
HIGHLIGHT: Now I am panicked and irritated — but also hopeful that I can get a reasonably priced policy.
I'm one of the many people in the United States who have had their individual health insurance policy canceled since the full implementation of the Affordable Care Act began Oct. 1. I own the Quintessence Group, a marketing consulting company based in Philadelphia. I have seven employees, but I've dodged the staff health insurance bullet for years because all of my employees have either had insurance through their spouses or have worked as independent contractors.
I offered a group health insurance plan through the company until 2007, when I reorganized. I finally decided to offer health insurance again in the summer of 2012 - after my divorce became final and I had to get an individual policy. The process was not easy, even though I was 39 and in good health. I applied to Aetna, where I had been covered on my ex-husband's policy, but was denied. The company pulled the results of a blood test during the underwriting process and decided a blood cholesterol score of 213 disqualified me. (The Mayo Clinic says that a score below 200 is desirable.)
What they didn't know is that I was on a medication before the test that has a side effect of elevating cholesterol. So this forced me to apply for the only other health insurance option in my market, Independence Blue Cross, which was happy to sell me a premium individual PPO policy for $447 a month. Four months later, after my 40th birthday, my premium was raised to $618 a month, which I thought was pretty expensive. With this insurance policy, I had $50 co-pays for regular doctor visits and experienced quite a bit of gap billing for lab work and minor in-office procedures. And, by the way, the policy did not include either dental or vision coverage.
And then, in October, I got a letter informing me that my policy would be discontinued effective Jan. 1. Now I am panicked and irritated - but also hopeful that I can get a reasonably priced policy, through the Affordable Care Act, that won't discriminate against my slightly elevated cholesterol, my race, my gender or any other preexisting condition.
I have not yet decided if my health insurance options would be better served offering group health insurance again or just getting another individual policy. As my research progresses, I will chronicle my journey to get a new policy. My first stop is HealthCare.gov. I'm also going to reach out to a health insurance broker for advice. I may find that it's more beneficial to make one of my contractors an employee and get a group plan instead. You must have at least two employees to apply for health insurance to qualify for a group plan.
Has the Affordable Care Act had an impact on your business?
Melinda F. Emerson is founder and chief executive of Quintessence Multimedia, a social media strategy and content development company. You can follow her on Twitter.
An Owner Figures Out How to Save on His Health Insurance
A Business Owner's First Brush With HealthCare.gov
A Small Business Starts to Navigate the Affordable Care Act
Small Business Health Exchanges Delayed Again
What I Needed to Understand About Health Insurance
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(You're the Boss)
November 27, 2013 Wednesday
Small Business Health Exchanges Delayed Again
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 988 words
HIGHLIGHT: The SHOP exchanges had been of most interest to a limited segment of the small-business market — those seeking tax credits.
With little more than a month before the new year - and many small businesses under pressure to make a decision about health insurance plans for 2014 - the Obama administration on Wednesday announced that the federally run small-business health insurance exchanges will not accept online enrollments for another year, until November 2014. It also announced that in the meantime, small businesses can enroll in exchange-listed plans through an insurance agent or broker, or directly with the carrier.
Exchanges under the Small Business Health Options Program, or SHOP, were originally scheduled to open in each state on Oct. 1. But the federal government, which is managing the exchanges for 36 states, and some states were unable to deploy fully functional exchanges by the initial deadline. On the federal exchanges, businesses can only create an account, and get an "overview," as the administration put it in a press release, of available plans - they could not get actual rate quotes, based on the ages of their employees, or submit applications online. (And as You're the Boss's Paul Downs discovered, submitting an application manually does not guarantee a response from the exchange.)
In late October, the administration promised that its exchanges would be up to full capability by the end of November. On Wednesday, the administration said that beginning next month, small businesses would be better able to compare plans anonymously in the online exchanges. But officials could not immediately say whether companies would be able to get specific rate quotes, based on their employee populations. Without that level of specificity, any comparison tool would probably be of limited use to small businesses that go shopping.
In any event, the SHOP exchanges may only appeal to a limited segment of the small-business market. Insurance brokers report that relatively few of their small clients are interested in the exchanges, because some of the exchanges are carrying fewer plans than are available outside the exchanges. Moreover, it appears that many businesses are choosing to renew existing policies rather than buy new plans that comply with the Affordable Care Act, such as would be available on the exchanges.
But the SHOP exchanges are crucial to at least one subset of small businesses: those eligible for the small-business health care tax credits created by the Affordable Care Act. Beginning in 2014, those tax credits will offset 50 percent of a business's insurance premium expense, provided the health plan meets the standards set by the law - and is purchased through a SHOP exchange.
They are a small subset of the small-business universe because the credits are fully available only to businesses with 10 or fewer employees that pay an average wage of $25,000 or less. The credits phase out as the number of employees grows to 25 and average wages rise to $50,000. These are the businesses least likely to offer health insurance, and a study by the Government Accountability Office last year found that the credit, which at the time amounted to 35 percent of premiums, was not big enough to induce businesses to reconsider. Other companies found the credit too complicated to try to claim.
The problems with the SHOP exchanges, however, have put some of those businesses seeking tax credits in a bind. Companies with insurance-plan years that begin Jan. 1 have had to choose between renewing outside of the exchange and forgoing the credit, or waiting to see if they could actually enroll through an exchange - and risk not having coverage if they couldn't. (Companies with plan years that begin later in the year do not have to switch to new plans purchased through the exchange on Jan. 1. Under the Internal Revenue Service's transition rules, a company can make the switch when its plan is normally up for renewal and still claim the tax credit for the entire year, so long as the employer paid at least half of the premiums of the previous plan.)
The Obama administration did make an accommodation to businesses seeking the tax credit on Wednesday: they no longer have to be certified by the government that they are eligible for the tax credits before enrolling in a health plan. Instead, a business will have to get the certification before filing its taxes.
"Although online enrollment will only be available in November 2014, we expect that making direct enrollment, tax credit applications and comparison shopping easier will help to ensure that small businesses can take full advantage of the marketplace and tax credits," in 2014, said Julie Bataille, a spokeswoman for the Centers for Medicare and Medicaid Services, the agency administering the exchanges.
Reaction to Wednesday's news, in dueling emailed statements, fell along predictable lines. Liberal-leaning groups made the best of it. "The marketplace is still the most important provision in the Affordable Care Act for small businesses and until the online portion is functional, small business owners will be able to purchase insurance through it exactly as they do now in the outside market," said John Arensmeyer, chief executive of the Small Business Majority, a liberal-leaning group originally formed to advance the Democrats' health care overhaul legislation.
But Kevin Kuhlman, a lobbyist for the National Federation of Independent Business, which challenged the law in the Supreme Court, countered: "The failure to get the small business exchanges online adds yet another onerous paperwork requirement for job creators. The continued delays add to uncertainty and contribute to the decision of many owners to take early renewals of their small-group plans."
What Does the Affordable Care Act Mean for Your Business?
What I Needed to Understand About Health Insurance
Obama Health Care Fixes Give Small Businesses Time to Assess
A Business Owner's First Brush With HealthCare.gov
A Small Business Starts to Navigate the Affordable Care Act
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May 29, 2014 Thursday
Businesses Less Gloomy About A.C.A. Impact on Hiring
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 213 words
HIGHLIGHT: A survey suggests that fewer businesses are expecting the new health care law to stifle hiring.
Are American businesses coming to terms with the Affordable Care Act? A new survey suggests so, though it's a tentative peace at best.
In the study, 54 percent of accountants who work with private businesses say they believe, based on conversations with business owners, that the health law makes it less likely that private companies will add new employees in the next year. That's a 12 percent improvement over last July, when fully two-thirds of accountants believed that the Affordable Care Act would stifle hiring.
The financial information firm Sageworks produced the study by surveying its clients in the accounting industry. (Accountants provide Sageworks with financial data about their business clients and then use its service to compare those clients against industry peers.) Just more than half of the respondents thought businesses would maintain their current number of employees, while nearly 19 percent said companies would expand their work forces. Last year, by comparison, almost 61 percent of accountants said business would maintain current staffing levels, and only 14 percent thought their clients would hire additional workers.
The share of accountants who thought business clients would actually cut jobs fell slightly, to 13 percent from about 14 percent.
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The New York Times
November 29, 2014 Saturday
Late Edition - Final
Critiquing a Republican's Alternative to Obamacare
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 16
LENGTH: 297 words
To the Editor:
Re ''An Obamacare Do-Over,'' by Ed Gillespie, an unsuccessful Republican candidate for the Senate (Op-Ed, Nov. 21): The substantive difference between Mr. Gillespie's health care plan and the Affordable Care Act is one of ethics. While the Affordable Care Act expands access to health care substantially, his plan would insure far fewer Americans and perpetuate the injustice of lack of access to affordable, quality health care.
The Democratic Party has a different vision from that of the Republican Party. It is based on equal opportunity for all Americans, and the decency, justice and solidarity that result from making shared sacrifices so that all Americans can enjoy the right to health care.
The plan Mr. Gillespie offers is heavy on dollar figures and claims of savings, but is ultimately exclusionary and short on civic and moral responsibility.
NOAM SCHIMMEL Montreal, Nov. 21, 2014
The writer is a fellow at the Center for Human Rights and Legal Pluralism, McGill University Faculty of Law.
To the Editor:
Ed Gillespie states that the Affordable Care Act is designed to lead to a single-payer system. That contention is hard to understand, given that the act leaves private insurance companies at the center of health care.
More objectionable, however, is the article's apparent, and unexplained, dismissal of a single-payer arrangement as a solution to the high cost and inadequacies of health care in the United States. It is widely accepted, even in this country, that most other industrialized nations, using a single-payer system or something close to it, achieve largely better health outcomes than we have here. And they do so at roughly half the cost per capita of what is spent on health care in the United States.
PETER BAKEWELL Bath, Me., Nov. 21, 2014
URL: http://www.nytimes.com/2014/11/29/opinion/critiquing-a-republicans-alternative-to-obamacare.html
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The New York Times
January 19, 2017 Thursday
Late Edition - Final
Trump's Health Secretary Pick Is Vague on Affordable Care Act Replacement
BYLINE: By ROBERT PEAR and THOMAS KAPLAN
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 1250 words
WASHINGTON -- Representative Tom Price, the man President-elect Donald J. Trump has chosen to lead the Department of Health and Human Services, promised on Wednesday to make sure people do not ''fall through the cracks'' if the Affordable Care Act is repealed, and set a goal to increase the number of people with health insurance.
But at a hearing before the Senate Health, Education, Labor and Pensions Committee, Mr. Price provided only vague reassurance to members of both parties who pressed him for specific policies.
Republicans concluded he was well qualified; Democrats were not satisfied.
''Just days ago, President-elect Trump promised, quote, 'insurance for everybody,''' said Senator Patty Murray of Washington, the senior Democrat on the committee. ''But Congressman Price, your own proposals would cause millions of people to lose coverage, force many people to pay more for their care, and leave people with pre-existing conditions vulnerable to insurance companies' rejecting them or charging them more.''
In four hours of testimony, Mr. Price, an orthopedic surgeon from the affluent northern suburbs of Atlanta, set lofty goals for a plan to replace the Affordable Care Act, President Obama's signature domestic achievement, but did not say how he would achieve them.
Mr. Price, 62, also denied impropriety in his trading of stocks in health care and pharmaceutical companies, saying he had left many details to his broker. The Wall Street Journal reported last month that he had traded more than $300,000 worth of shares while promoting legislation that could have affected the companies he owned stock in.
Senator Al Franken, Democrat of Minnesota, said one investment looked like a ''sweetheart'' deal. But Mr. Price said, ''I had no access to nonpublic information.''
Like several other candidates for top jobs in the Trump administration, Mr. Price put a little distance between himself and the president-elect on several issues.
Mr. Trump said last week that drug companies were ''getting away with murder'' and that Medicare should negotiate with drugmakers to secure lower prices, a position long championed by Democrats and fiercely opposed by Republicans.
Asked if he would press Congress to authorize such negotiations, Mr. Price did not give a definitive answer. ''I think we need to find solutions to the challenges of folks' gaining access to needed medication,'' he said.
He added that, if confirmed, he would try to give states more freedom and flexibility under Medicaid, the federal-state program that provides coverage for more than 70 million low-income people. In response to questions, he said states should be allowed to require certain able-bodied adults without children to work, seek work or participate in job training as a condition of receiving Medicaid. Some Republican governors want to impose such requirements, but the Obama administration has turned down their proposals.
Mr. Price praised Indiana's program to expand Medicaid eligibility under the Affordable Care Act with conservative policies that state officials say promote ''personal responsibility.''
''States know best'' how to care for their Medicaid beneficiaries, he said, adding, ''What Indiana has done is really a best practice, I think, for many other states to follow.''
Mr. Trump has not said much about the future of Medicaid in the 31 states that have expanded eligibility, with large amounts of federal money.
Democratic senators were often frustrated in their efforts to get Mr. Price to say whether he supported the coverage requirements and insurance mandates in the Affordable Care Act.
In a typical response, he said that patients should have ''access to the kind of coverage that they want,'' rather than having it dictated to them by the government.
Senator Christopher S. Murphy, Democrat of Connecticut, said that Mr. Price appeared to support the coverage and protections provided by the Affordable Care Act, but that ''we don't get any specifics as to how that's going to occur'' if the law is repealed.
Without mandating coverage of specific benefits, Mr. Price said, the Trump administration could ''make certain that individuals had the care and the kind of coverage that they needed for whatever diagnosis would befall them.''
He said the administration could put in place ''a different construct'' that ''would allow for every single person to gain access to the coverage that they want and have nobody fall through the cracks.''
He did not say how the Trump team would guarantee such protection.
Mr. Trump has expressed support for a provision of the 2010 health law under which insurers must allow children to stay on their parents' policies until the age of 26. This is ''baked into the insurance programs that are out there right now,'' Mr. Price said.
''I think that the insurance industry has included individuals up to age 26 on their parents' policies virtually across the board,'' he said, ''and I don't see any reason that that would change.''
Democrats were skeptical. Senator Maggie Hassan of New Hampshire said there was no guarantee that such protections would continue in the absence of federal requirements. Insurance companies did not routinely cover drug abuse treatment in the past and might not do so in the future without a requirement, she said.
The Congressional Budget Office said Tuesday that the number of uninsured Americans could increase by 18 million in one year if Congress repealed major parts of the health care law while leaving others. Mr. Price tried on Wednesday to allay fears of disruption.
''I think there's been a lot of talk about individuals losing health coverage,'' Mr. Price said. ''That is not our goal, nor is it our desire, nor is it our plan.''
''One of the important things that we need to convey to the American people is that nobody's interested in pulling the rug out from under anybody,'' he said. ''We believe that it's absolutely imperative that individuals that have health coverage be able to keep health coverage and move, hopefully, to greater choices and opportunities for them to gain the kind of coverage that they want for themselves and for their families.''
Mr. Price said he would ''absolutely'' consider administrative action to stabilize the market for insurers, which are supposed to submit proposals for 2018 coverage in April. Insurers say it will be nearly impossible to calculate premiums if they have no idea what will replace the health care law.
Mr. Price championed ''medical innovation'' as an essential ingredient of high-quality care but criticized the Center for Medicare and Medicaid Innovation, which was created by the health law to test new ways of paying doctors, hospitals and other providers.
He said that the agency had great promise, but that too often, its experiments were compulsory for doctors and nearly nationwide in scope. He said he ''adamantly opposed the mandatory nature'' of some payment models, like one for joint replacement surgery and one for expensive drugs administered in doctors' offices.
Mr. Price said he would not object if Medicare tested payment methods with small pilot projects that could expand if successful.
The health committee will not vote on Mr. Price's nomination. Another hearing has been scheduled for Tuesday by the Senate Finance Committee, which will vote on whether to recommend confirmation. The committees share authority over issues for which the Health and Human Services Department is responsible.
URL: http://www.nytimes.com/2017/01/18/us/politics/nominee-for-health-secretary-is-vague-on-replacing-affordable-care-act.html
LOAD-DATE: January 19, 2017
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GRAPHIC: PHOTO: Representative Tom Price of Georgia, the candidate for health and human services secretary, at his hearing on Wednesday. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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December 16, 2016 Friday
Late Edition - Final
Republicans Plan to Replace Obama's Health Care Law With 'Universal Access'
BYLINE: By ROBERT PEAR and THOMAS KAPLAN
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 893 words
WASHINGTON -- House Republicans, responding to criticism that repealing the Affordable Care Act would leave millions without health insurance, said on Thursday that their goal in replacing President Obama's health law was to guarantee ''universal access'' to health care and coverage, not necessarily to ensure that everyone actually has insurance.
In defending the Affordable Care Act, the Obama administration, congressional Democrats and advocacy groups have focused on the 20 million people covered by the law, which has pushed the percentage of Americans without health insurance to record lows. The American Medical Association recently said that ''any new reform proposal should not cause individuals currently covered to become uninsured.''
But House Republicans, preparing for a rapid legislative strike on the law next month, emphasize a different measure of success.
''Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,'' a House leadership aide told journalists on the condition of anonymity at a health care briefing organized by Republican leaders.
Republicans have an ''ironclad commitment'' to repeal the law, the aide said, as lawmakers moved to discredit predictions that many people would lose coverage.
''There's a lot of scare tactics out there on this,'' said Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee. ''We can reassure the American public that the plan they are in right now, the Obamacare plans, will not end on Jan. 20,'' the day Donald J. Trump will be inaugurated.
The suggestion that 20 million people will lose coverage is a ''big lie,'' Mr. Brady said, after meeting here with Republican members of his committee.
''Republicans,'' he said, ''will provide an adequate transition period to give people peace of mind that they will have those options available to them as we work through this solution.''
Republicans have not settled on the details or the timing of their replacement plan. The House speaker, Paul D. Ryan of Wisconsin, portrays repeal of the law not as an ideological crusade, but as a form of urgently needed relief.
''Insurance markets are collapsing,'' Mr. Ryan said this week. ''Premiums are soaring. Patients' choices are dwindling.''
The House leadership aide said that repealing major provisions of the law was a priority for the first 100 days of the Trump administration. But, he said, the date that those provisions would actually disappear would be delayed, allowing a transition period as short as two years or as long as three or four years. During that time, Republicans plan to pass one or more replacement bills.
By giving people the choice to buy insurance, Republicans could end up dangerously skewing the health insurance market, Obama administration officials and insurance executives say. Sick people are more likely to sign up, they say, and there may not be enough healthy people paying premiums to cover the costs for those who are less healthy.
Under the Affordable Care Act, people who go without insurance are subject to tax penalties. The Internal Revenue Service says that more than eight million tax returns included penalty payments for people who went without coverage in 2014.
The House leadership aide said that lowering the cost of insurance was a much better way to encourage people to opt in.
''We would like to get to a point where we have what we call universal access, where everybody is able to access coverage to some degree or another,'' the aide said. ''Over the past six years, if you look at the experience we've had with the A.C.A. rollout, chasing coverage doesn't necessarily yield great outcomes. You can have people going into an exchange, finding out that their pediatrician is no longer available to them.''
The aide said House Republicans had not decided on the future of cost-sharing subsidies that are paid by the federal government to insurance companies. Such subsidies are intended to reduce out-of-pocket costs for millions of low-income people buying insurance under the Affordable Care Act.
A federal district judge, responding to a lawsuit filed by the House, ruled in May that the Obama administration had paid billions of dollars to insurers since January 2014 even though Congress had not appropriated money for such ''cost-sharing reductions,'' and that the payments therefore violated the Constitution. Without that money, estimated at $130 billion over 10 years, insurers would increase premiums or pull out of the insurance exchanges, creating chaos for consumers, some health policy experts say.
But now that the House leadership has won a legal victory, Republicans have not decided how to proceed. The aide declined on Thursday to say if Republicans would seek an immediate halt to the cost-sharing subsidy payments. He did not rule out the possibility that a Republican-controlled Congress might keep the money flowing for a transition period, to stabilize the market while Republicans develop alternatives to the health law.
''It's an open question,'' he said.
Republicans said they were more interested in vindicating Congress's constitutional power of the purse.
In any event, the House leadership aide said, Republicans do not intend to pull the rug out from people who have gained insurance under the Affordable Care Act.
URL: http://www.nytimes.com/2016/12/15/us/politics/paul-ryan-affordable-care-act-repeal.html
LOAD-DATE: December 16, 2016
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GRAPHIC: PHOTO: Speaker Paul D. Ryan portrayed repeal of the health law not as an ideological crusade, but as a form of urgently needed relief. (PHOTOGRAPH BY SAM HODGSON FOR THE NEW YORK TIMES)
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January 5, 2017 Thursday
Late Edition - Final
Republicans' Four-Step Plan for Dismantling the Care Act
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1254 words
WASHINGTON -- Vice President-elect Mike Pence and the top Republicans in Congress made clear on Wednesday, more powerfully and explicitly than ever, that they are dead serious about repealing the Affordable Care Act.
How they can uproot a law deeply embedded in the nation's health care system without hurting some of the 20 million people who have gained coverage through it is not clear. Nor is it yet evident that millions of Americans with pre-existing medical conditions will be fully protected against disruptions in their health coverage.
But a determined Republican president and Congress can gut the Affordable Care Act, and do it quickly: a step-by-step health care revolution in reverse that would undo many of the changes made since the law was signed by President Obama in March 2010.
Step 1: Defang the filibuster
The Senate intends to pass a budget resolution next week that would shield repeal legislation from a Democratic filibuster. If the Senate completes its action, House Republican leaders hope that they, too, can approve a version of the budget resolution next week. Whether they can meet that goal is unclear.
The resolution contains seemingly innocuous language, instructing four committees that control health care policy -- two in the Senate, two in the House -- to draft legislation within their jurisdiction that would cut at least $1 billion from the deficit over 10 years. But that language has real teeth. The legislation produced to meet those instructions can pass the Senate with a simple majority -- 51 votes if all senators are present -- obliterating the power of the Democratic minority to block it.
Those four committees would have just a few weeks, until Jan. 27, to produce legislation repealing major provisions of the Affordable Care Act. House Republicans have some practice at this, because they have voted more than 60 times since 2011 to repeal some or all of the law.
The budget blueprint will guide Congress but will not be presented to the president for a signature or veto.
Step 2: Add the details
The committees -- House Energy and Commerce, House Ways and Means, Senate Finance, and Senate Health, Education, Labor and Pensions -- will quickly assemble legislation intended to eviscerate the health care law.
The repeal legislation will be in the form of a reconciliation bill, authorized by the Congressional Budget Act of 1974. Such bills can be adopted under special fast-track procedures. But Senate rules generally bar the use of those procedures for measures that have no effect on spending or revenue. So the legislation, as now conceived, would probably leave the most popular provisions of the health law intact, such as the prohibition on insurers' denying coverage to people with pre-existing conditions.
Instead, the legislation would:
â- Eliminate the tax penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.
â- Eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid.
â- Repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.
It could also repeal some of the taxes and fees that help pay for the expansion of coverage under the Affordable Care Act. But some Republicans have indicated that they may want to use some of that revenue for their as-yet-undetermined plan to replace the health care law.
The 2010 law imposed taxes and fees on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices, among others. Republicans have not said for sure which taxes they will scrap and which they may keep.
Republicans say they will delay the effective date of their repeal bill to avoid disrupting coverage and to provide time for them to develop alternatives to Mr. Obama's law. They disagree over how long the delay should last, with two to four years being mentioned as possibilities.
Step 3: The new president's role
Within days of taking office, President-elect Donald J. Trump plans to announce executive actions on health care. Some may undo Obama administration policies. Others will be meant to stabilize health insurance markets and prevent them from collapsing in a vast sea of uncertainty.
''We are working on a series of executive orders that the president-elect will put into effect to ensure that there is an orderly transition, during the period after we repeal Obamacare, to a market-based health care economy,'' Mr. Pence said at the Capitol on Wednesday.
He did not provide details, and Trump transition aides said they had no information about the executive orders. But some options are apparent. The federal government could continue providing financial assistance to insurance companies to protect them against financial losses and to prevent consumers' premiums from soaring more than they have in the last few years.
Step 4: Find a replacement
Even as they move full speed toward gutting the existing health law, Republicans are scrambling to find a replacement. At the moment, they have no consensus.
Mr. Pence said on Wednesday that the replacement would probably encourage greater use of personal health savings accounts and make it easier for carriers to sell insurance across state lines. Also, he said, it would encourage small businesses to band together and buy insurance through ''association health plans'' sponsored by business and professional organizations.
Some type of subsidy or tax credit for consumers, to help defray the cost of premiums, is also likely. States would have more authority to set insurance standards, and the federal government would have less.
Mr. Trump has also endorsed the idea of state-run ''high-risk pools'' for people with pre-existing conditions who would otherwise have difficulty finding affordable coverage.
Many experts have said that repealing the health law without a clear plan to replace it could create havoc in insurance markets. Doctors, hospitals and insurance companies do not know what to expect.
Without an effective requirement for people to carry insurance, and without subsidies to buy it, supporters of the law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.
Democrats in Congress say they will do everything they can to thwart Republican efforts to dismantle the Affordable Care Act. They plan to dramatize their case by publicizing the experiences of people whose lives have been saved or improved by the law.
In the Senate next week, Democrats will demand votes intended to put Republicans on record against proposals that could protect consumers. Defenders of the law also hope to mobilize groups like the American Cancer Society and the American Heart Association to speak up for patients.
The Senate Democratic leader, Chuck Schumer of New York, and the House Democratic leader, Nancy Pelosi of California, are encouraging their colleagues to organize rallies around the country on Jan. 15 to oppose the Republicans' health care agenda.
And to buttress their case, Democrats are compiling statistics from the White House and from researchers at liberal-leaning groups like the Center on Budget and Policy Priorities, the Commonwealth Fund and the Urban Institute, which warn of catastrophic consequences if the law is repealed.
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URL: http://www.nytimes.com/2017/01/04/us/affordable-care-act-congress-repeal-plan.html
LOAD-DATE: January 5, 2017
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GRAPHIC: PHOTO: Senator Mitch McConnell, right, with Vice President-elect Mike Pence on Wednesday. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A12)
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September 23, 2014 Tuesday
Affordable Care Act Disappearing From Midterm Ads
BYLINE: Nicholas Confessore
SECTION: US; politics
LENGTH: 110 words
HIGHLIGHT: Is President Obama’s health care law the incredible shrinking wedge issue? Repealing or scaling back the law has been a long-running Congressional battle — House Republicans have staged over 50 votes on the issue — and was widely expected to be the tip of the spear in the party’s efforts to win back the Senate […]
Is President Obama's health care law the incredible shrinking wedge issue?
Repealing or scaling back the law has been a long-running Congressional battle - House Republicans have staged over 50 votes on the issue - and was widely expected to be the tip of the spear in the party's efforts to win back the Senate this fall.
But with the exception of a bump in July, the Affordable Care Act is getting mentioned less and less in general election ads shown by Republicans and conservative groups. Courtesy of the Campaign Media Analysis Group, here is the monthly percentage of Senate general election advertising containing an antihealth care law message:
Credit
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(Taking Note)
November 21, 2012 Wednesday
Boehner's Rearguard Guerrilla Action
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 529 words
HIGHLIGHT: He said health care reform should be "on the table" in fiscal cliff talks.
No one thought it would be easy for President Obama and Republicans in Congress to negotiate a package of tax increases and spending cuts over the next few weeks. But now Speaker John Boehner is trying to make the process even harder. In an op-ed article for the Cincinnati Enquirer today, Mr. Boehner said that "we need to repeal Obamacare" because it adds to the debt and is unaffordable. As a result, he wrote, "the law has to stay on the table as both parties discuss ways to solve our nation's massive debt challenge."
That ignores the plain words of the most reliable and non-partisan judge of these things - the Congressional Budget Office - which said in July that the Affordable Care Act doesn't add to the debt, it lowers the debt. Repealing the law would add $109 billion to the debt through 2022. (The Supreme Court, in fact, made the law $84 billion cheaper when it ruled that states don't have to accept the law's Medicaid expansion.)
More broadly, though, Mr. Boehner is not simply ignoring the results of this month's election, he is openly defying them. Not only did Mr. Obama and many congressional Democrats win with full-throated support for the reform law, but exit polls showed that only 25 percent of voters agree with the Republican goal of full repeal.
Remarkably, the speaker admitted this in the article. "Over the past couple of years," he wrote, "I have noted there are essentially three major routes to repeal of the president's law: the courts, the presidential election process and the congressional oversight process. With two of those three routes having come up short, the third and final one becomes more important than ever."
The Supreme Court has ruled the law constitutional, but he still opposes it. The people have spoken, but his mind is made up. Now the only route left to him is a kind of rearguard guerilla action: taking budget potshots at the law, using spending bills and regulations to hobble its implementation.
Mr. Boehner also noted in his op-ed that the House Ways and Means Committee has already issued a subpoena to learn how much the administration has spent in promoting the law. But there's nothing wrong with using taxpayer dollars to promote it - it's "the law of the land," as Mr. Boehner himself acknowledged recently, and the government needs to show people how to use it. Given the refusal of many Republican governors to implement the law in their states, it is particularly important for the White House to explain what steps are necessary to get insurance coverage.
Republicans may succeed in their goal of making it harder for poor people to get health insurance, but the White House made it clear today that changes to the law won't even be considered in the fiscal cliff talks. Mr. Boehner undoubtedly knows this, and may be trying to look tough to his right flank before the inevitable compromises to come. For those depending on the law to escape the endless lines at emergency rooms, this kind of gamesmanship is an unwelcome reminder of unyielding Republican opposition.
A First Look at Second Term Obama
Boehner's Opening Gambit
Who Has a Mandate?
Anti-Abortion, Pro-Democrat
The President Fumbles the Court Issue
LOAD-DATE: November 22, 2012
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February 20, 2017 Monday
Late Edition - Final
Obama Gone, Critics of Health Law Go Quiet
BYLINE: By JONATHAN MARTIN
SECTION: Section A; Column 0; National Desk; POLITICAL MEMO; Pg. 11
LENGTH: 933 words
WASHINGTON -- For seven years, few issues have animated conservative voters as much as the repeal of the Affordable Care Act. But with President Barack Obama out of office, the debate over ''Obamacare'' is becoming less about ''Obama'' and more about ''care'' -- greatly complicating the issue for Republican lawmakers.
Polling indicates that more Republicans want to make fixes to the law rather than do away with it. President Trump, who remains popular on the right, has mused about a replacement plan that is even more expansive than the original. The conservative news media are focused more on Mr. Trump's near-daily skirmishes with Democrats and reporters, among others, than on policy issues like health care. And the congressional debate, as well as the paid advertisements on both sides, is centered on the substance of the law rather than its namesake, draining some of its toxicity on the right.
As liberals overwhelm congressional town hall-style meetings and deluge the Capitol phone system with pleas to protect the health law, there is no similar clamor for dismantling it, Mr. Obama's signature legislative accomplishment. From deeply conservative districts in the South and the West to the more moderate parts of the Northeast, Republicans in Congress say there is significantly less intensity among opponents of the law than when Mr. Obama was in office.
''I hear more concerns than before about 'You're going to repeal it, and we're all going to lose insurance' because they don't think we're going to replace it,'' said Representative Mike Simpson, a Republican who represents a conservative district in Idaho.
Since Mr. Obama signed the Affordable Care Act into law, about 20 million Americans have gained insurance because of it. And millions more who had pre-existing health conditions have been able to obtain coverage under the law. At the same time, many Americans have seen their premiums rise or their choices of insurance carriers dwindle.
But it was not until now, with the Republicans taking control of the federal government, that the debate fully shifted from the theoretical to the tangible. It was easy for conservatives to rally against a law identified with a president they despised when he was capable of vetoing any repeal. Now that he is gone and the law's benefits appear to be on the chopping block, the people who stand to lose the most are the most vocal.
''I've heard from constituents who have been harmed by the Affordable Care Act over the course of its being in existence,'' said Representative Leonard Lance, Republican of New Jersey, whose affluent district Mr. Trump narrowly lost last year. ''More recently, because of our discussions on repairing it, I've heard from those who do not wish to have the act amended. More recently, that is the preponderance of those who have contacted me.''
It is a longstanding rule of politics that rallying opposition to a proposal is usually easier than galvanizing support. And never is this more the case than when a widely distributed benefit is at risk of being taken away.
''I was here in 2009 and 2010, and we're not getting the anti-Obamacare calls like that,'' said Representative Brett Guthrie, a Kentucky Republican who is on one of the committees tasked with rewriting the law. ''I think people are going to hold us accountable for making sure we not only repeal, but we have a law in place that creates a better opportunity for people.''
The demands from conservative-leaning constituents in districts like Mr. Guthrie's are plainly shifting. In a nationwide CBS News poll last month, 53 percent of Republicans said they wanted to change the law to make it work better while 41 percent said they wanted to abolish it.
Overhauling the law, however, is far more politically complicated than simply scrapping it. Congressional Republican leaders were met with a backlash from their own ranks after it emerged that they were considering financing a new law by ending the longstanding practice of letting employers exclude from taxation the health benefits they offer.
''Our voters do expect action, but as you make changes you become vulnerable to attack,'' Representative Tom Cole of Oklahoma said. ''This is fraught with difficulties, no doubt about it.''
Adding to the anxiety is Mr. Trump, who is a wild card on the health law. His health secretary, Tom Price, signaled to House Republicans at a private meeting on Thursday that the administration would let Congress draft a replacement bill, Mr. Cole said.
But the president has said multiple times that he is uneasy about depriving anybody of health insurance, and he may bridle if Democrats attack any Republican plan that may lead to that.
As Democrats note, Mr. Trump owes his victory in part to voters who have benefited from the law.
''A lot of economically vulnerable Republican voters have come to rely on government's involvement in making sure they have affordable health care,''said Geoff Garin, a Democratic pollster.
And with Mr. Trump and Republican lawmakers facing less pressure from the right than the left, conservative groups worry that the party will not ultimately have the stomach to repeal the law, which Republicans have been running against since 2010.
''Voters gave Republicans the charge to repeal and replace Obamacare, and the continued delays and discussions about repairing Obamacare need to stop,'' David McIntosh, the head of the Club for Growth, a conservative advocacy group, said last week.
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URL: http://www.nytimes.com/2017/02/19/us/politics/affordable-care-act-critics.html
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GRAPHIC: PHOTO: President Barack Obama signing the Affordable Care Act at the White House in 2010. As lawmakers hear an outcry from the law's supporters, there is no longer a clamor for dismantling it, Republicans say. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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The New York Times
January 27, 2017 Friday 00:00 EST
Obamacare Sabotage
BYLINE: VIKAS BAJAJ
SECTION: OPINION
LENGTH: 305 words
HIGHLIGHT: The Trump administration's cancellation of health care sign-up ads could prove costly.
The Trump administration doesn't have a plan to replace the Affordable Care Act, but it's already trying to sabotage the law. It has canceled advertisements meant to encourage people to pick insurance policies on HealthCare.gov ahead of the Jan. 31 sign-up deadline.
This is a shameless attempt to drive down enrollment, especially among young people, who tend to wait until the last minute to get insurance but who are essential to the program because they tend to be healthier than older people and thus help spread the cost. Lower enrollment gives President Trump more ammunition in his fight against what he calls "the failed Obamacare disaster."
He and congressional Republicans have pledged to replace the law. And based on what lawmakers and Mr. Trump's choice to run the Department of Health and Human Services have said, the replacement could be a much inferior law that takes insurance away from millions and leaves others with bare-bones policies.
As of Christmas Eve, more than 11.5 million people had signed up on the federal and state health insurance exchanges, up nearly 300,000 from a comparable period a year earlier. The Obama administration had predicted total sign-ups of 13.8 million by the end of January.
The Trump administration says that by canceling the ads they are simply finding "efficiencies where they exist." But officials who worked on the Affordable Care Act until just before the inauguration say that the ads had already been paid for. Even if some or all of the $5 million spent on those ads is refunded to the government, canceling them at this late stage is counterproductive and could prove very costly to the health care system and to people who don't get insurance.
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(You're the Boss)
November 14, 2012 Wednesday
For Business Owners, the Health Care Details Begin to Emerge
BYLINE: PAUL DOWNS
SECTION: BUSINESS; smallbusiness
LENGTH: 715 words
HIGHLIGHT: A business owner gets his annual health care renewal rates -- along with a rundown of the many changes to come.
Last week, before the election, I received a fat envelope from Independence Blue Cross with our health insurance renewal rates for 2013. This happens about this time each fall, and it is not something I look forward to.
I've had a couple of good years -- my rates fell in 2010 and 2011 -- but this was preceded by a long string of years with double-digit increases. Which is discouraging, because the astronomic rise in costs wasn't accompanied by any apparent rise in the quality of the health care we have been getting. Co-pays have gone up. Drugs have gotten more expensive. At the doctor's office they still hand me that stupid clipboard with the paper questionnaire to fill out, then they make me wait another 30 minutes to see the doctor. Most problematic, in my opinion: I still can't find a price list for any of the doctor's routine services. So I have no way to compare the costs.
I open the envelope, wade through the pages of boilerplate and finally get to the heart of the matter. For the third year in a row, my rates have dropped. It's not a huge amount, about 5 percent, but it's better than another increase. The monthly charge for a single person has dropped from $330.89 to $315.23, and the rate for family coverage fell from $971.26 a month to $925.31. To put this in perspective, here are the rates for my cheapest policy options for the last seven years:
The drop from the peak in 2010 is significant, but I'm still paying 50 percent more for insurance that I was in 2005.
The envelope from Blue Cross was followed by an e-mail from our benefits administrator, with a spreadsheet attached that recapped all of the pricing information and added a whole lot more. Most of it was procedural, laying out the steps required for me to renew the policies for all my workers. But one of the tabs in the sheet was titled "Health Care Reform" and laid out all of the ways that the Affordable Care Act -- a k a Obamacare -- would be changing the landscape. It's a long list, sorted by date, and progressing from now until the date of full implementation in 2014. This item in particular caught my eye:
"Effective March 2013: Employers must provide a new notice to all employees explaining the availability of Exchanges and whether or not the employee may be eligible for insurance affordability programs through the Exchange. The notice must be provided to new employees upon date of hire. Guidance is pending."
Scrolling further down the page, there was more:
"Effective January 1 2014: All U.S. citizens and legal residents must maintain 'minimum essential coverage.' Failure to obtain minimum essential coverage will result in financial penalties for groups with more than 50 employees. Some exceptions apply."
And effective the same date, this:
"Health insurance will be available for purchase through the exchanges. Private and nonprofit insurers as well as states will offer small employers (up to 100 employees) the ability to purchase health insurance. Large employers (more than 100 employees) may purchase coverage through the exchanges beginning in 2017. Employers will not be required to purchase coverage through an exchange."
Ah, the crux of the matter. Within a year I'll have some idea of what it will save me (and cost my employees) to stop providing health insurance. I'll have the option to let my workers get their own coverage, just the same way they get car and house insurance. I have not made up my mind whether this is a good idea or not, but soon I'll have some real numbers to think about.
With President Obama's re-election, the Affordable Care Act will be fully implemented. I voted for him, twice, partially in hope that something would be done about the health care mess. So this is what I get.
How about you? What has happened to your rates? What are you finding in your renewal packages? What do the health care changes mean for your company?
Paul Downs founded Paul Downs Cabinetmakers in 1986. It is based outside Philadelphia.
Having Lost the Health Care Battle, the N.F.I.B. Readies for a Long War
Why the Health Care Tax Credit Eludes Many Small Businesses
Small Business Health Insurance: Costs Still Going Up
The Affordable Care Act Rebate Checks Are in the Mail: Now What?
A Small Restaurant Gets a Big Increase in Health Premiums - and Misses the Tax Credit
LOAD-DATE: November 28, 2012
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(Taking Note)
June 8, 2012 Friday
Shooting at Laws in Ads (Literally)
BYLINE: LAWRENCE DOWNES
SECTION: OPINION
LENGTH: 443 words
HIGHLIGHT: Ron Gould says he won't back down from liberals at The Times, just like he won't back down from liberals in Washington.
Ron Gould, an Arizona state senator running for Congress, really, really doesn't want government to mess with anybody's health care. I noted that in a post yesterday, linking to a campaign ad that shows him blasting President Obama's health-care reform, the Affordable Care Act, with a pump-action shotgun.
He doesn't actually hunt it down to kill it. It gets launched into the air in front of him, like a big, 900-page clay pigeon. He then blows it to bits. He is, after all, "a straight shooter."
I think Mr. Gould liked my post, because he immediately used it in a fund-raising appeal. "I won't back down from the liberals at the New York Times editorial page," he says, "just like I won't back down from the liberals in Washington who want to keep raising the debt limit to pay for their endless cycle of spending that will do nothing more than ruin the economic prosperity of our country."
Mr. Gould was the sponsor of a bill in the state Legislature to nullify the Affordable Care Act in Arizona. It declares that the act and a companion reconciliation measure "are not authorized by the Constitution of the United States and violate its true meaning and intent as given by the founders and ratifiers and are declared to be invalid in this state, shall not be recognized by this state, are specifically rejected by this state and are considered void and of no effect in this state."
That's making your views pretty clear.
I have not yet met Mr. Gould, but if I do, I'd like to ask him if he really means what he says about government-run health care. Since there is no government-run health care in Mr. Obama's plan, do you want to (O.K., figuratively) shoot up Medicare and Medicaid, and Veterans Affairs medical centers and clinics, and military hospitals? Aren't there senior citizens in Phoenix and Glendale who depend on government health care for their prescription drugs? Who are the troops supposed to go to when they get blown away? Halliburton? And if you take your seat in Congress, are you not going to sign up for the members' health plan? I hear it's a good one.
I should note that Mr. Gould is not the first or only candidate to shoot a law in a political ad. In 2010 a Democrat, Joe Manchin, used a scope-mounted rifle to assassinate a cap-and-trade bill. He is now the junior senator from West Virginia.
In an ad from Herman Cain's Cain Solutions, a man and a young girl do a terrible thing to a rabbit to make a point about the burden placed on small businesses by the tax code.
'Washington Doesn't Get Us'
The Most Expensive Campaign Ever
We're Fox News and We Approved This Message
What Will President Obama Say?
How to Energize the Liberal Base
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(Taking Note)
June 11, 2015 Thursday
On Health Care Reform, Nothing to Fear but the Scaremongers
BYLINE: TERESA TRITCH
SECTION: OPINION
LENGTH: 349 words
HIGHLIGHT: Republicans said the Affordable Care Act would lead employers to cut workers’ hours. That hasn’t happened.
A linchpin of the Affordable Care Act is that large employers must either provide health coverage for employees who work at least 30 hours a week, or pay a penalty.
As with every other part of the law, Republican opponents concocted a scare story around that provision, saying that employers would cut workers' hours in order to avoid the law's requirements.
As with other health-care scare stories, facts have trumped the scaremongering.
Each month, the Labor Department measures the number of part-time workers. It also measures whether the part-timers are "involuntary," defined as those who would prefer full-time work if they could get it, or "voluntary," defined as those who work part time because they want to.
Between early 2014 and early 2015, as the health care law came into effect, the number of involuntary part-timers fell by 699,000, the biggest year-over-year drop in records that go back to 1994.
Over the same period, the number of voluntary part-timers increased by 765,000, or 3.9 percent, record high increases in the data.
These findings, in a recent report by the Center for Economic and Policy Research, are good news on two fronts. Clearly, the predicted spike in involuntary part-time employment did not happen. What apparently did happen is that many full-time employees who wanted to work part time opted to do so once they no longer needed employer-provided coverage.
Greater opportunity for workers to determine their work lives is a plus for the economy. An increase in voluntary part-timers, for example, can create openings and hours for other workers.
Having failed to scare Americans out of participating in the health reform, opponents have now hung their roll-back hopes on the Supreme Court, asking the justices to rule on a technicality in the law that could cause nearly 6.4 million low- and moderate-income Americans in 34 states to lose their coverage. The decision is expected in the coming weeks.
The truly fearful aspect of the law is the opponents' determination to undermine it, against all evidence that it is working as well as could reasonably be hoped.
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(Economix)
October 22, 2013 Tuesday
Little Sign of Jobs Impact From Health Care Law
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 211 words
HIGHLIGHT: The number of part-time workers for economic reasons was virtually unchanged last month, and far lower than a year ago.
Is the Affordable Care Act causing a surge in part-time employment?
According to the September jobs report, no - at least not yet. The number of part-time workers for economic reasons increased ever so slightly, to 7.93 million from 7.91 million. But that's down from 8.6 million a year ago. Indeed, there's still little sign that the Affordable Care Act has had much of an impact on employment one way or another.
Why? Well, the so-called "employer mandate" does not come into effect until 2015. Economists expect some businesses to hire more part-time workers to avoid the mandate, but do not think it is likely that they would do so until late next year. The provisions of the law that are currently in place, such as a rule preventing insurers from discriminating against applicants with pre-existing conditions, are unlikely to have any effect on hours worked or employment.
So what is driving the decrease in part-time work? Probably the same trends behind the falling unemployment rate: in part an improving economy, and in part the continued bleeding of workers from the labor force.
Fed Shift Now Seems More Distant
The Employment Rate Remains Stuck
In Belated Jobs Report, a Search for Clues
Medicaid and the Incentive to Work
Economic Data Starts Flowing Again
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The New York Times
October 29, 2016 Saturday
Late Edition - Final
Keeping an Affordable Care Act Plan Affordable May Require Some Shopping Around
BYLINE: By ANN CARRNS.
Email: yourmoneyadviser@nytimes.com
SECTION: Section B; Column 0; Business/Financial Desk; YOUR MONEY ADVISER; Pg. 3
LENGTH: 642 words
INSURER defections and double-digit premium increases may be making consumers wary of seeking health insurance through Affordable Care Act marketplaces. But despite the turmoil, health care advocates are still urging people to shop for 2017 coverage when the annual open enrollment period begins on Tuesday.
''Go shopping,'' said Elisabeth Benjamin, vice president for health initiatives with the Community Service Society in New York. ''You may be eligible for more financial help than you think.''
Premiums for benchmark plans on HealthCare.gov, the federal marketplace, are increasing by an average of 25 percent, the government said. But 85 percent of those insured through the marketplace are eligible for tax credits that can significantly lower those premiums.
In many parts of the country, tax credits can reduce premium increases to ''essentially zero,'' Cynthia Cox, associate director of Kaiser Family Foundation's program for the study of health reform and private insurance, said this week in a call with reporters.
And because tax credits and financial help increase when premiums increase, some people may be eligible for assistance next year even if they weren't this year. ''As premiums go up, so do premium tax credits,'' said Elizabeth Hagan, senior policy analyst with Families USA, an advocacy group.
The catch is that keeping the lowest possible premium may require consumers to change plans, which can mean switching doctors -- a hassle many people want to avoid, especially if they have complex medical conditions.
Still, ''as long as they're willing to shop around and change plans,'' Ms. Cox said, they can save money.
About 11 million people are enrolled in marketplace plans. The federal government estimates that 2.5 million people who pay full price by buying individual coverage could qualify for financial help if they shopped on the marketplace instead.
Changes in premiums for 2017 plans vary widely, according to an analysis from the Kaiser foundation.
Cities like Phoenix and Birmingham, Ala., will have sharp increases in premiums for ''benchmark'' silver plans before the application of tax credits. But premiums for such plans in Indianapolis, Cleveland and Providence, R.I., will decrease.
Even in markets where just one insurer is participating, however, consumers generally have a choice of plans, Ms. Hagan said.
In New York, where the average increase is about 17 percent, Ms. Benjamin said low-income families and individuals could qualify for an ''essential'' plan that has no deductible and a monthly premium of either nothing or $20 a month. The option was offered for the first time for 2016, and about 360,000 people are enrolled, she said.
Here are some questions and answers about marketplace open enrollment:
When is open enrollment for marketplace plans this year?
Open enrollment runs from Nov. 1 until Jan. 31, 2017. But you must enroll by Dec. 15 if you want your coverage to start on Jan. 1.
Consumers can't enroll in coverage until Tuesday, but they can prepare now by previewing available plans on HealthCare.gov.
Where can I get help choosing a plan?
Advocates recommend meeting in person with a trained assister or ''navigator,'' who can help you compare options. ''This is hard stuff,'' Ms. Benjamin said. ''Don't do it by yourself.'' On HealthCare.gov, you can click on ''find local help'' to search for assistance by ZIP code. You will also find a checklist of information and documents you will need to enroll.
Advocates recommend setting up an appointment soon, so you will have time to consider options and ask questions without pressure. ''Try not to wait until the last minute,'' said Erin Singleton, chief of mission delivery for the Patient Advocate Foundation.
What is the penalty for going without health coverage?
The minimum penalty is now about $700 per adult.
URL: http://www.nytimes.com/2016/10/29/your-money/keeping-affordable-care-act-plan-affordable.html
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October 10, 2013 Thursday
Late Edition - Final
Exchanges' Flaws Justify Law's Delay, G.O.P. Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; IN PRACTICE; Pg. 20
LENGTH: 464 words
WASHINGTON -- House Republicans said Wednesday that chaos in the first nine days of open enrollment under President Obama's health care law would justify a delay in major provisions of the law, including tax penalties for people who go without insurance in 2014.
The comments came at a hearing of a House committee, where a senior official of the Internal Revenue Service said that its work on the new insurance marketplaces was ''going fine,'' just as planned.
The official, Sarah Hall Ingram, director of the Affordable Care Act office at the I.R.S., said the agency had ''processed several hundred thousand responses'' to queries about the income of taxpayers seeking subsidies to lower the cost of insurance purchased through the new marketplaces, also known as exchanges.
''I.R.S. systems to support enrollment in the marketplaces were launched on schedule and are working as planned,'' Ms. Hall Ingram said. The tax agency, she said, had no role in the computer systems of the federal exchange, created and operated by the Department of Health and Human Services.
In the last week, millions of people have tried to use the Web site for the federal exchange, healthcare.gov, but experienced long delays and were often unable to create the online accounts needed to compare health plans and premiums.
''Obamacare's first week has been a mess,'' said the committee chairman, Representative Darrell Issa, Republican of California. ''This law is not ready for prime time.''
Representative John J. Duncan Jr., Republican of Tennessee, said, ''This is the most messed-up, convoluted, confusing law that's ever been passed.''
The Obama administration has had three and a half years to work on the law, Mr. Duncan said, so ''it is ridiculous, and kind of sad,'' that the government was so poorly prepared for the rollout of the program this week.
In July, the White House announced a one-year delay, until 2015, in the law's requirement that larger employers offer health insurance to full-time employees. Republicans said it was unfair for the government to delay the employer mandate while enforcing the requirement for consumers to have coverage, especially because it was proving so difficult to buy insurance on many exchanges.
The senior Democrat on the committee, Representative Elijah E. Cummings of Maryland, said, ''There will continue to be challenges implementing this law.'' But, he added, ''Once we work out the kinks in Obamacare, we will have something that will benefit society long after we are dead.''
Ms. Hall Ingram was previously in charge of the I.R.S. office accused of giving special scrutiny to conservative groups that sought tax-exempt status, but she denied ever applying political criteria.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/news/affordable-care-act/2013/10/09/house-republicans-argue-for-delay-in-health-law-penalties/
LOAD-DATE: October 10, 2013
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GRAPHIC: PHOTO: Sarah Hall Ingram is director of the Affordable Care Act office at the I.R.S. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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The New York Times
June 26, 2015 Friday
Late Edition - Final
Justices Give Obama Another Health Care Victory
BYLINE: By ADAM LIPTAK; Julie Hirschfeld Davis and Michael D. Shear contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1402 words
WASHINGTON -- The Supreme Court ruled on Thursday that President Obama's health care law allows the federal government to provide nationwide tax subsidies to help poor and middle-class people buy health insurance, a sweeping vindication that endorsed the larger purpose of Mr. Obama's signature legislative achievement.
The 6-to-3 ruling means that it is all but certain that the Affordable Care Act will survive after Mr. Obama leaves office in 2017. For the second time in three years, the law survived an encounter with the Supreme Court. But the court's tone was different this time. The first decision, in 2012, was fractured and grudging, while Thursday's ruling was more assertive.
''Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,'' Chief Justice John G. Roberts Jr. wrote for a united six-justice majority. In 2012's closely divided decision, Chief Justice Roberts also wrote the controlling opinion, but that time no other justice joined it in full.
In dissent on Thursday, Justice Antonin Scalia called the majority's reasoning ''quite absurd'' and ''interpretive jiggery-pokery.''
He announced his dissent from the bench, a sign of bitter disagreement. His summary was laced with notes of incredulity and sarcasm, sometimes drawing amused murmurs in the courtroom as he described the ''interpretive somersaults'' he said the majority had performed to reach the decision.
''We really should start calling this law Scotus-care,'' Justice Scalia said, to laughter from the audience.
In a hastily arranged appearance in the Rose Garden on Thursday morning, a triumphant Mr. Obama praised the ruling. ''After multiple challenges to this law before the Supreme Court, the Affordable Care Act is here to stay,'' he said, adding: ''What we're not going to do is unravel what has now been woven into the fabric of America.''
The ruling was a blow to Republicans, who have been trying to gut the law since it was enacted. But House Speaker John A. Boehner vowed that the political fight against it would continue.
''The problem with Obamacare is still fundamentally the same: The law is broken,'' Mr. Boehner said. ''It's raising costs for American families, it's raising costs for small businesses and it's just fundamentally broken. And we're going to continue our efforts to do everything we can to put the American people back in charge of their health care and not the federal government.''
The case concerned a central part of the Affordable Care Act that created marketplaces, known as exchanges, to allow people who lack insurance to shop for individual health plans. Some states set up their own exchanges, but about three dozen allowed the federal government to step in to run them. Across the nation, about 85 percent of customers using the exchanges qualify for subsidies to help pay for coverage, based on their income.
The question in the case, King v. Burwell, No. 14-114, was what to make of a phrase in the law that seems to say the subsidies are available only to people buying insurance on ''an exchange established by the state.''
A legal victory for the plaintiffs, lawyers for the administration said, would have affected more than six million people and created havoc in the insurance markets and undermined the law.
Chief Justice Roberts acknowledged that the plaintiffs had strong arguments about the plain meaning of the contested words. But he wrote that the words must be understood as part of a larger statutory plan. ''In this instance,'' he wrote, ''the context and structure of the act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase.''
This was challenging, he said, in light of the law's ''more than a few examples of inartful drafting,'' a consequence of rushed work behind closed doors that ''does not reflect the type of care and deliberation that one might expect of such significant legislation.''
But he said the law's interlocking parts supported a ruling in favor of the subsidies, particularly given that a contrary decision could have given rise to chaos in the insurance markets. A ruling rejecting subsidies in most of the nation would have left in place other parts of the law, including its guarantee of coverage regardless of pre-existing conditions, its requirement that most Americans obtain insurance or pay a penalty, and its expansion of Medicaid.
Without the subsidies, many people would be unable to afford insurance, and healthier consumers would go without coverage, leaving insurers with a sicker, more expensive pool of customers. That would raise prices for everyone, leading to what supporters of the law called death spirals.
''The statutory scheme compels us to reject petitioners' interpretation,'' Chief Justice Roberts wrote, referring to the challengers, ''because it would destabilize the individual insurance market in any state with a federal exchange, and likely create the very 'death spirals' that Congress designed the act to avoid.''
In dissent, Justice Scalia wrote that the majority had stretched the statutory text too far.
''I wholeheartedly agree with the court that sound interpretation requires paying attention to the whole law, not homing in on isolated words or even isolated sections,'' Justice Scalia wrote. ''Context always matters. Let us not forget, however, why context matters: It is a tool for understanding the terms of the law, not an excuse for rewriting them.''
''Reading the act as a whole leaves no doubt about the matter,'' he wrote. '' 'Exchange established by the state' means what it looks like it means.''
Justice Scalia said the decision had damaged the court's reputation for ''honest jurisprudence.''
The court, he said, had taken into its own hands a matter involving tens of billions of dollars that should have been left to Congress.
''The court's decision reflects the philosophy that judges should endure whatever interpretive distortions it takes in order to correct a supposed flaw in the statutory machinery,'' Justice Scalia wrote.
''It is up to Congress to design its laws with care,'' he added, ''and it is up to the people to hold them to account if they fail to carry out that responsibility.''
Justices Clarence Thomas and Samuel A. Alito Jr. joined Justice Scalia's dissenting opinion.
Chief Justice Roberts rejected the argument that Congress had limited the availability of subsidies in order to encourage states to create their own exchanges, a notion that had occurred to almost no one at the time the law was enacted.
Sixteen states and the District of Columbia have established their own exchanges. Under the law, the federal government has stepped in to run exchanges in the rest of the states.
''The whole point of that provision,'' Chief Justice Roberts wrote, ''is to create a federal fallback in case a state chooses not to establish its own exchange. Contrary to petitioners' argument, Congress did not believe it was offering states a deal they would not refuse -- it expressly addressed what would happen if a state did refuse the deal.
Justices Anthony M. Kennedy, Ruth Bader Ginsburg, Stephen G. Breyer, Sonia Sotomayor and Elena Kagan joined the majority opinion. In the 2012 case, Justice Kennedy was in dissent.
The case started when four plaintiffs, all from Virginia, sued the Obama administration, saying the phrase meant that the law forbids the federal government to provide subsidies in states that do not have their own exchanges.
The plaintiffs challenged an Internal Revenue Service regulation that said subsidies were allowed whether the exchange was run by a state or by the federal government. They said the regulation was at odds with the Affordable Care Act.
In July, the United States Court of Appeals for the Fourth Circuit, in Richmond, Va., ruled against the challengers.
Judge Roger L. Gregory, writing for a three-judge panel of the court, said the contested phrase was ''ambiguous and subject to multiple interpretations.'' That meant, he said, that the I.R.S. interpretation was entitled to deference.
The Supreme Court's ruling was more forceful. ''This is not a case for the I.R.S.,'' Chief Justice Roberts wrote. ''It is instead our task to determine the correct reading.''
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URL: http://www.nytimes.com/2015/06/26/us/obamacare-supreme-court.html
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GRAPHIC: PHOTOS: President Obama and Vice President Joseph R. Biden Jr. in the White House on Thursday after the Supreme Court's decision. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
MAJORITY: ''A fair reading of legislation demands a fair understanding of the legislative plan. Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.'' (A1)
Above, demonstrators expressed their support for the Affordable Care Act outside of the Supreme Court on Thursday. Left, copies of the court's ruling in favor of nationwide health insurance subsidies were rushed to television news reporters. (PHOTOGRAPHS BY DOUG MILLS/THE NEW YORK TIMES) (A16)
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December 12, 2014 Friday
Issa Issues Subpoena to Obama Health Consultant
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 184 words
HIGHLIGHT: Darrell Issa, the California Republican who is giving up the chairmanship of the House Oversight Committee is seeking testimony from Jonathan Gruber, the economist who advised the Obama administration on the Affordable Care Act.
And now, a parting shot from Representative Darrell Issa.
Mr. Issa, a California Republican who is giving up the chairmanship of the House Oversight Committee, has issued one more subpoena, he said on Friday, seeking testimony from Jonathan Gruber, the economist who advised the Obama administration on the Affordable Care Act.
"As one of the architects of Obamacare, Jonathan Gruber is in a unique position to shed light on the 'lack of transparency' surrounding the passage of the president's health care law, however he has so far been unwilling to fully comply with the Oversight Committee's repeated requests," Mr. Issa said in a written statement.
Mr. Gruber has drawn criticism from Republicans for incendiary comments about how the "stupidity of the American voter" enabled the passage of the health law.
This week, Mr. Gruber apologized for his "arrogance," but said that he was not the architect of the policy.
Mr. Issa said that Mr. Gruber had failed to answer key questions about the law and that he was requesting that Mr. Gruber turn over any correspondence related to his work with the government.
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June 11, 2015 Thursday
Late Edition - Final
States and Congress Urged to Act if Justices Rule Against Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 754 words
WASHINGTON -- The Obama administration's top health care official said Wednesday that if the Supreme Court stopped the payment of health insurance subsidies to millions of Americans, it would be up to Congress and state officials to devise a solution.
''The critical decisions will sit with Congress and states and governors,'' Sylvia Mathews Burwell, the secretary of health and human services, said at a hearing of the House Ways and Means Committee.
Ms. Burwell and the White House have said that they have no contingency plans to deal with the chaos that could result if the court strikes down subsidies in the pending case, King v. Burwell.
The plaintiffs in that case, four Virginia residents, contend that federal law allows subsidies only in states that have established their own insurance marketplaces, not in states that rely on the federal exchange.
Republicans in Congress are drafting legislation to respond if the court blocks subsidies in more than 30 states where people buy insurance through the federal marketplace, HealthCare.gov.
But Ms. Burwell on Wednesday denounced a leading Republican proposal, set forth in a bill introduced by Senator Ron Johnson of Wisconsin.
The bill, supported by at least 31 other Republican senators, would continue tax credits on premiums through August 2017 for consumers who might otherwise lose them as a result of a Supreme Court decision.
The Republican bill would also repeal provisions of the Affordable Care Act that mandate most Americans have health insurance and require larger employers to provide it.
''This bill in its current form is repeal,'' Ms. Burwell said of Mr. Johnson's legislation. ''And the president has said he will not sign something that repeals the act.''
The hearing got off to a fast start. The chairman of the Ways and Means Committee, Representative Paul D. Ryan, Republican of Wisconsin, skipped the usual pleasantries and jumped right into criticism of the health care law and the way it had been carried out by President Obama.
''Obamacare is just flat busted,'' Mr. Ryan said. ''It just doesn't work, and no fix can change that fact. Its central principle is government control. That means higher prices, fewer choices and lower quality. The answer isn't just to tighten a few screws. The answer is to repeal and replace this law with patient-centered reforms.''
After listening to Ms. Burwell for two hours on Wednesday, Mr. Ryan expressed frustration. Administration officials, he said, ''refuse to entertain the notion that the health care law might be struck down,'' and they have not developed a backup plan.
The senior Democrat on the committee, Representative Sander M. Levin of Michigan, defended the law, telling Republicans: ''What's busted is not the Affordable Care Act, but your attacks on it, endless attacks. You never come up with single comprehensive alternative.''
Republicans complain about ''government control,'' Mr. Levin said, but the fact is that ''more and more people are getting insurance through the private sector.''
Mr. Ryan said the administration was acting illegally in providing some types of financial assistance to reduce medical costs for low-income people.
''Congress wields the power of the purse,'' Mr. Ryan said. ''More and more, the administration is acting like a purse snatcher.''
Under the Affordable Care Act, insurance companies must reduce co-payments, deductibles and other out-of-pocket costs for some people in health plans purchased through the new public insurance exchanges. The federal government reimburses insurers for the ''cost-sharing reductions.''
House Republicans say the Obama administration never received an appropriation to make these payments to insurance companies.
Mr. Ryan and other Republicans assert that the spending violates the Constitution, which says, ''No money shall be drawn from the Treasury, but in consequence of appropriations made by law.''
Mr. Obama requested the money as part of the budget he sent to Congress in April 2013, but Congress did not act on the request. Seeing the issue as an urgent priority, the administration began making the payments in early 2014, using money from a separate account established for tax refunds and tax credits.
Ms. Burwell said that the spending was legal. Republicans challenged the spending in a lawsuit filed against the administration in November.
That lawsuit, House of Representatives v. Burwell, is pending in Federal District Court here and is separate from the Supreme Court case.
URL: http://www.nytimes.com/2015/06/11/us/affordable-care-act-insurance-premium-subsidies.html
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The New York Times
March 15, 2017 Wednesday
Late Edition - Final
The Republican Health Plan, Under Fire
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 22
LENGTH: 645 words
To the Editor:
Re ''24 Million Among Uninsured Under G.O.P. Plan'' (front page, March 14):
The Congressional Budget Office calculates billions of dollars of cost savings to the federal government with the Republican health care bill. Sorry, but where is the cost calculation for the millions who will be sicker without insurance and use hospitals and emergency rooms anyway? Someone is going to pay for it. Or will we leave our ill and frail at the doorstep of a hospital and hope for the best?
SUZANNE SMYTHE, ESSEX, CONN.
To the Editor:
In light of Republican attempts to delegitimize the Congressional Budget Office scoring of the Republican health care bill, it is worth noting that Keith Hall, the current director of the C.B.O., was appointed by this Republican-majority Congress less than two months after the party took control of both houses in 2015. At the time he was praised and strongly promoted by the current secretary of health and human services, then-Representative Tom Price.
RICHARD FUCHS, NEW YORK
The writer, a doctor, is a clinical professor of medicine at Weill Cornell Medical College.
To the Editor:
Re ''A Bill So Bad It's Awesome'' (column, March 10):
Paul Krugman is right that Speaker Paul Ryan does not deserve his reputation as a serious policy wonk.
Here is one example: I heard him complaining that under the Affordable Care Act, healthy people subsidize sick people and promising that the Republican bill would fix that ''problem.''
Is it really possible that Mr. Ryan does not even know the underlying principle of insurance? Everyone at risk pays into an insurance fund. Enough healthy people need to contribute to the risk pool without using services themselves so it has enough money to pay for the sick or injured person's care.
Since everyone has a probability of needing care, health insurance has value for all. What people buy with insurance is peace of mind. That healthy people subsidize sick people is not a ''problem''; it is the very essence of insurance.
STEPHEN M. DAVIDSON, BOSTON
The writer is a professor at the Questrom School of Business, Boston University, and the author of ''A New Era in U.S. Health Care.''
To the Editor:
Are the Democrats going to mimic the Republicans by spending their years out of office doing nothing about health care? This is the time to work together to come up with proposals to fix the problems with the Affordable Care Act. Assuming that the Republican proposals do not pass, the Democrats should be ready with some ideas. It is apparent that the act needs major improvements.
The Republican proposals don't address the real problems, and people's lives are in the balance. Perhaps behind the curtains, Democrats and Republicans should quietly work together for a program that will do its best to cover the most people.
ESTHER REITER, CHICAGO
To the Editor:
Thanks to ''Wealthy Would Get Big Tax Cut Under Affordable Care Act Repeal Plan'' (news article, March 11), it is now clear that one of the main reasons the Republicans are so rabidly driven to repeal the act is to cut taxes on the wealthy.
I -- and probably most Americans -- did not realize that part of the funding of the act came from taxing the richest 1 percent. Now the light shines. So the repeal of the Affordable Care Act will do two things: take more money from the middle class as it pays more for health care and increase the wealth of the richest 1 percent.
Taken together, repeal of the act will further widen the gap between the rich and the poor. That is not a good direction for our country.
JUDY L. KLEVANLA CRESCENT, MINN.
The writer is a pediatrician.
To the Editor:
Do I have this right? Republicans in Congress want to give mentally ill people access to firearms but want to limit their access to mental health coverage under Medicaid? Just checking.
MARK STEIN, LARCHMONT, N.Y.
URL: http://www.nytimes.com/2017/03/14/opinion/the-republican-health-plan-under-fire.html
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The New York Times
January 27, 2017 Friday 00:00 EST
In Private, Republican Lawmakers Agonize Over Health Law Repeal
BYLINE: ROBERT PEAR and THOMAS KAPLAN
SECTION: US; politics
LENGTH: 1662 words
HIGHLIGHT: An audio recording of a closed-door meeting reveals concerns that contrast with the confidence party leaders and President Trump express in public.
WASHINGTON - Congressional Republicans, meeting behind closed doors this week in Philadelphia, expressed grave concerns about dismantling the Affordable Care Act on the urgent timetable demanded by President Trump, fretting that, among other things, they could wreck insurance markets and be saddled with a politically disastrous "Trumpcare."
An audio recording of a session at their annual retreat, obtained by The New York Times, shows Republicans in disarray, far from agreement on health policy, and still searching for something to replace former President Barack Obama's health care law. While their leaders called for swift action to rescue consumers from the Affordable Care Act, some backbench Republicans worried about potential pitfalls.
"We had better be sure that we are prepared to live with the market being created," said Representative Tom McClintock of California, because "that's going to be called Trumpcare."
He added, "Republicans will own it lock, stock and barrel, and we'll be judged on that."
When Democrats were writing the Affordable Care Act seven years ago, their primary goal was to provide health insurance to more people, an ambition that the Obama administration went to great lengths to fulfill as it enrolled millions of people in Medicaid or private health plans.
Now, as Republicans try to devise a replacement for the law, they have set a nearly impossible standard for themselves: They have promised that none of the 20 million people who gained coverage through the Affordable Care Act will lose it if the law is repealed, even as they lift its mandates and penalties, pull back the tax increases that pay for it and pledge to enact a new program that will be cheaper for taxpayers and consumers.
In their private session, the recording of which was first reported on by The Washington Post, Republicans revealed that they understood the predicament they had largely created for themselves.
"I recognize that we can't keep Obama's promises," Representative Tom MacArthur of New Jersey said. "They were wrong to begin with, and the system can't be sustained." He worried aloud about the possibility that some people could lose insurance as the law is unwound.
"We're telling those people that we're not going to pull the rug out from under them, and if we do this too fast, we are, in fact, going to pull the rug out from under them," Mr. MacArthur said. After giving states the choice to expand Medicaid under the law, he said, reversing that expansion too quickly would run the risk of pulling a "bait and switch with the states."
The lawmakers' concerns contrasted with the confidence that Republican leaders and President Trump have expressed as they rush to replace Mr. Obama's signature domestic achievement, also known as Obamacare. Congress this month approved a budget blueprint that clears the way for quick action to repeal major provisions of the law, and Mr. Trump has said Congress should repeal and replace the law at the same time, putting pressure on lawmakers to agree on an alternative.
That budget measure created an aspirational deadline to draft repeal legislation by Jan. 27, a day that came and went.
Privately, Republicans made clear they understand the risks they are running. At their session this week, they voiced concern that their efforts to undo the law could have harmful consequences, such as inadvertently destabilizing insurance markets - a concern shared by Democrats and insurers.
Under Senate rules, the Senate could vote to repeal major provisions of the Affordable Care Act using fast-track procedures that neutralize the threat of a Democratic filibuster. "We can repeal parts of it," Mr. McClintock said, "and the parts that remain, I'm concerned, could make the market even more dysfunctional."
Republican leaders tried to reassure anxious backbenchers, making the same points in private as they have in public.
"We don't own Obamacare," said Senator John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, adding: "We are the rescue party. We campaigned to provide relief and help repair the damage."
Republican leaders have predicted that Democrats will come to the table to help draft a replacement once it becomes clear that the health law will be repealed. But some rank-and-file members were not so sure.
Representative John Katko of New York wondered what Republicans would do "if we can't get anything out of the Democrats."
Another New York Republican, Representative John J. Faso, warned colleagues they were playing with fire if they cut off funds for Planned Parenthood clinics, as Speaker Paul D. Ryan has said Republicans intend to do.
"Health insurance is going to be tough enough for us to deal with, without allowing millions of people on social media to come to Planned Parenthood's defense," Mr. Faso said. He wanted to know from the administration that "we're not going to have a tweet from the president" saying "we should protect Planned Parenthood."
"We're making a grave mistake including this Planned Parenthood provision in a health care bill," he said.
For many Republicans, coverage and cost are still the most important issues. Estimates of the number of people who will gain or lose coverage will affect the outlook for any proposal to dismantle and replace the 2010 law. If the Congressional Budget Office, the nonpartisan scorekeeper on Capitol Hill, concludes that a significant number of people could lose coverage under a Republican plan, opposition from lawmakers - including Republicans - could jeopardize passage.
Before Mr. Trump stepped into the debate with his call for "insurance for everybody," Republicans were choosing their words with utmost caution: Their goal in replacing the health law was to guarantee "universal access," they said, not necessarily universal coverage.
"We will give everyone access to affordable health care coverage," Mr. Ryan said in early December when asked if Republicans had a plan to cover everyone.
But that discipline has broken down as lawmakers hear from constituents terrified of losing insurance and as Mr. Trump weighs in.
"No one who has coverage because of Obamacare today will lose that coverage," Representative Cathy McMorris Rodgers of Washington, the chairwoman of the House Republican Conference, said on Jan. 10.
A spokeswoman for Ms. McMorris Rodgers later tried to clarify what she had said. The congresswoman "didn't deliver her remarks exactly as prepared," the spokeswoman said. In the prepared remarks, Ms. McMorris Rodgers included an important qualification: "No one who has coverage because of Obamacare today will lose that coverage the day it's repealed" - in the transition to a new market-oriented health care system.
But Senator John Cornyn of Texas, the No. 2 Senate Republican, has made a sweeping commitment just like the one by Ms. McMorris Rodgers. After meeting with governors on Jan. 19, Mr. Cornyn was asked about concerns that people who benefited from the expansion of Medicaid might lose that coverage with a repeal.
"We're all concerned, but it ain't going to happen," Mr. Cornyn said. He amplified the point, adding: "Nobody's going to lose coverage. Obviously, people covered today will continue to be covered. And the hope is we'll expand access. Right now 30 million people are not covered under Obamacare."
A spokesman for Mr. Cornyn said he "meant no one will lose access to coverage."
Chris Jacobs, a health policy analyst who used to work for Republicans in Congress, said Republicans and Mr. Trump were at risk of overpromising, just as Mr. Obama did.
"Conservatives should not remain fixated on the number of people with health insurance when designing an Obamacare alternative," Mr. Jacobs said. "We will never win the battle with liberals if you measure success in terms of how many people have health insurance cards. We don't want to spend as much as liberals, and we don't believe in coercing people to buy insurance."
Democrats remember how Republicans hounded Mr. Obama for breaking his promise that "if you like your health care plan, you can keep your health care plan." Democrats say they will hold congressional Republicans and the Trump administration accountable in the same way.
Increasing the number of people with insurance was a lodestar for the Obama administration. It spent tens of millions of dollars advertising the benefits of the law. It extended deadlines to give people more time to sign up. It allowed many people to sign up outside the regular annual enrollment period and played down the significance of big premium increases, saying consumers could get subsidies to defray the costs.
Republicans say they can get the same results for less money and without a statutory mandate that most Americans have insurance. But without that requirement, budget analysts say, it will be difficult for Republicans to achieve coverage gains as large as those achieved under the Affordable Care Act.
"It's easier for the Congressional Budget Office to estimate significant coverage effects if there is a federal requirement" for people to have insurance, said Douglas W. Elmendorf, who was the budget office director from 2009 to 2015. "It would be very hard to maintain the levels of insurance coverage we have now without the penalties and subsidies."
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Robert Pear reported from Washington, and Thomas Kaplan from Philadelphia.
PHOTO: House Speaker Paul D. Ryan, Republican of Wisconsin, center, has expressed confidence in public over his party's rush to replace the Affordable Care Act. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A11)
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December 2, 2016 Friday 00:00 EST
G.O.P. Plans Immediate Repeal of Health Law, Then a Delay
BYLINE: ROBERT PEAR, JENNIFER STEINHAUER and THOMAS KAPLAN
SECTION: US; politics
LENGTH: 1377 words
HIGHLIGHT: Congressional Republicans plan to move quickly to repeal the Affordable Care Act, but they are also likely to delay the effective date.
WASHINGTON - Republicans in Congress plan to move almost immediately next month to repeal the Affordable Care Act, as President-elect Donald J. Trump promised. But they also are likely to delay the effective date so that they have several years to phase out President Obama's signature achievement.
This emerging "repeal and delay" strategy, which Speaker Paul D. Ryan discussed this week with Vice President-elect Mike Pence, underscores a growing recognition that replacing the health care law will be technically complicated and could be politically explosive.
Since the law was signed by Mr. Obama in March 2010, 20 million uninsured people have gained coverage, and the law has become deeply embedded in the nation's health care system, accepted with varying degrees of enthusiasm by consumers, doctors, hospitals, insurance companies and state and local governments.
Unwinding it could be as difficult for Republicans as it was for Democrats to pass it in the first place and could lead Republicans into a dangerous cul-de-sac, where the existing law is in shambles but no replacement can pass the narrowly divided Senate. Democrats would face political pressure in that case as well.
It is not sheer coincidence that at least one idea envisions putting the effective date well beyond the midterm congressional elections in 2018.
"We are not going to rip health care away from Americans," said Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee, which shares jurisdiction over health care. "We will have a transition period so Congress can develop the right policies and the American people can have time to look for better health care options."
Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said: "I imagine this will take several years to completely make that sort of transition - to make sure we do no harm, create a good health care system that everyone has access to, and that we repeal the parts of Obamacare that need to be repealed."
But health policy experts suggest "repeal and delay" would be extremely damaging to a health care system already on edge.
"The idea that you can repeal the Affordable Care Act with a two- or three-year transition period and not create market chaos is a total fantasy," said Sabrina Corlette, a professor at the Health Policy Institute of Georgetown University. "Insurers need to know the rules of the road in order to develop plans and set premiums."
Details of the strategy are in flux, and there are disagreements among Republicans about how to proceed. In the House, the emerging plan, tightly coordinated between Mr. Ryan and Mr. Pence, is meant to give Mr. Trump's supporters the repeal of the health law that he repeatedly promised at rallies. It would also give Republicans time to try to assure consumers and the health industry that they will not instantly upend the health insurance market, and to pressure some Democrats to support a Republican alternative.
"I don't think you have to wait," Representative Kevin McCarthy of California, the majority leader, told reporters this week. "I would move through and repeal and then go to work on replacing. I think once it's repealed, you will have hopefully fewer people playing politics, and everybody coming to the table to find the best policy."
Under the plan discussed this week, Republicans said, repeal will be on a fast track. They hope to move forward in January or February with a budget blueprint using so-called reconciliation instructions, which would allow parts of the health care law to be dismembered with a simple majority vote, denying Senate Democrats the chance to filibuster. They would follow up with legislation similar to a bill vetoed in January, which would have repealed the tax penalties for people who go without insurance and the penalties for larger employers who fail to offer coverage.
That bill would also have eliminated federal insurance subsidies, ended federal spending for the expansion of Medicaid, and barred federal payments to Planned Parenthood clinics.
But in the Senate, Republicans would need support from some Democrats if they are to replace the Affordable Care Act.
The budget reconciliation rules that would allow Republicans to dismantle the Affordable Care Act have strict limits. The rules are primarily intended to protect legislation that affects spending or revenues. The health law includes insurance market standards and other policies that do not directly affect the budget, and Senate Republicans would, in many cases, need 60 votes to change such provisions.
Repealing the funding mechanisms but leaving in place the regulations risks a meltdown of the individual insurance market. Insurers could not deny coverage, but they would not get as many healthy new customers as they were expecting. Hospitals would again face many uninsured patients in their emergency rooms, without the extra Medicaid money they have been expecting.
Even a delay of two to three years could be damaging. Health policy experts said the uncertainty could destabilize markets, unnerving insurers that have already lost hundreds of millions of dollars on policies sold in insurance exchanges under the Affordable Care Act.
"Insurers would like clarity on the shape of the replacement plan to continue participating on exchanges if Obamacare is repealed," Ana Gupte, an analyst at Leerink Partners who follows the insurance industry, said Friday.
Republicans are hoping that Mr. Trump will be able to use his bully pulpit to lean on vulnerable Democrats up for re-election in states Mr. Trump won, such as Senators Joe Manchin III of West Virginia and Jon Tester of Montana.
"When that date came and you did nothing, if you want to play politics, I think the blame would go to people who didn't want to do anything," Mr. McCarthy said.
But Democrats may not be so quick to break.
"If they are looking at fixing what's there, I've been wanting to work with Republicans for years now," said Mr. Tester, whose state cast just 36 percent of its vote for Hillary Clinton. "But if they are going to take away provisions like pre-existing conditions, lifetime caps, 26-year-olds, I think they are barking up the wrong tree."
And some moderate Republicans see peril in repealing first and replacing later, favoring instead a simultaneous replacement to ensure a smooth transition.
"We are firing live rounds this time," Representative Charlie Dent, Republican of Pennsylvania, said. "If we repeal under reconciliation, we have to replace it under normal processes, and does anyone believe that the Senate Democrats, with their gentle tender mercies will help us?"
Republicans said they would work with the Trump administration on replacement legislation that would draw on comprehensive plans drafted by Mr. Ryan and Representative Tom Price, the Georgia Republican picked by Mr. Trump to be his secretary of health and human services.
Any legislation is likely to include elements on which Republicans generally agree: tax credits for health insurance; new incentives for health savings accounts; subsidies for state high-risk pools, to help people who could not otherwise obtain insurance; authority for sales of insurance across state lines; and some protection for people with pre-existing conditions who have maintained continuous coverage.
Republicans said they hoped that the certainty of repeal would increase pressure on Democrats to sign on to some of these ideas.
Democratic leaders, for now, feel no such pressure. Republicans "are going to have an awfully hard time" if they try to repeal the health law without proposing a replacement, said Senator Chuck Schumer of New York, the next Democratic leader. "There would be consequences for so many millions of people."
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PHOTO: Speaker Paul D. Ryan signing a measure in January to repeal major provisions of the Affordable Care Act. It was vetoed by President Obama. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES) (A15)
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February 16, 2015 Monday
Late Edition - Final
The Health Law, in the Real World
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 16
LENGTH: 800 words
To the Editor:
As Elisabeth Rosenthal eloquently documents in ''Insured, but Not Covered'' (news analysis, Sunday Review, Feb. 8), our health insurance system is little better than the nonsystem we had before the Affordable Care Act.
President Obama's reform was doomed by the failure to exclude the major profit-driven industries (health insurance, drug manufacturers and for-profit, hospital-based medical-industrial corporations) from taking it over and milking it for profits.
Virtually all of the problems (excluding the initial enrollment difficulties) can be attributed to tactics intended to transfer more cost to the consumer (and the government, which is ultimately us), while delivering higher profits for less actual care, which we are discouraged from seeking.
Congressional Republicans propose to turn even more of the system over to private, for-profit entities; instead, we should be instituting ''improved Medicare for all.'' Covering everyone equally, and eliminating time- and money-consuming confusion with a clearly defined, dependable system, relatively simple to understand and administer, would save billions of dollars while providing better care.
NANCY T. BLOCK
Berkeley Heights, N.J.
The writer is a psychiatrist.
To the Editor:
The news analysis by Elisabeth Rosenthal is a good examination of the Affordable Care Act and its effect on many Americans. I can relate, as I watched my monthly premium go to $539 a month from $285 and my yearly deductible to $3,500 from $2,500.
True, the health law brought coverage to many in need, but it has also created a mess for many of us. Rather than rail against the entire law and call for its repeal no matter what, reasonable people need to talk across the aisle and take a cold, hard look at how to provide the coverage that is needed.
The stories told in the news analysis are not outliers: I am hearing similar tales from people I know.
Being disappointed in the Affordable Care Act is not a partisan issue.
DORALEE HALPERIN
Washington
To the Editor:
The new health care marketplace requires that all who use it transform themselves into savvy consumers who must master complex regulations about costs from one company and one plan to another, and constantly keep abreast of ever-changing narrow networks.
This is difficult enough for healthy people, but for someone with a chronic, complex or debilitating illness, transforming oneself into a professional shopper becomes an impossible task. Such people may be unable to continue treatment with doctors who know them and who have come to understand their particular condition over time.
In Canada and many other advanced countries, when people get sick, they go to the doctor -- any doctor -- and pay virtually nothing. There, sick people can focus on getting better without the disruptions in care and the financial stress that are par for the course in an American system structured largely to ensure profits for the insurance industry.
JAY FRANKEL
Maplewood, N.J.
To the Editor:
Although the political stalemate in Washington makes it highly unlikely that the health law will be improved any time soon, it is worth trying to understand the full picture in the hope that one day it will become possible to perfect it.
One place to start is with the concept of a network of covered providers. The justification for networks is to allow insurers to partner with providers (doctors, hospitals and others) to find and carry out new ways of delivering care to increase quality and in the process keep down costs.
In the current context, however, a network becomes just another way to decrease the chance that an insurer will need to pay for a patient's use of services. How else to explain, as recounted in the article, that the closest in-network ear, nose and throat specialist for a child on Long Island is in Albany!
Gridlock at the federal level may make it impossible to improve the underlying legislation, but since insurance is regulated by the states, we should be able to turn to that level of government -- certainly in enlightened states like New York and California -- to adopt rules that forbid that kind of perversion of a reasonable idea.
STEPHEN M. DAVIDSON
Brookline, Mass.
The writer, a professor at the Boston University School of Management, is the author of ''A New Era in U.S. Health Care: Critical Next Steps Under the Affordable Care Act.''
To the Editor:
It's time to acknowledge that Republican criticism of the Affordable Care Act is based on the very real anger of millions of constituents at the disruption in their health care coverage. How the already insured could have been so badly treated by this law is hard to understand.
The president and the Democrats owe them an apology.
ANDREA ECONOMOS
Scarsdale, N.Y.
URL: http://www.nytimes.com/2015/02/16/opinion/the-health-law-in-the-real-world.html
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(You're the Boss)
July 9, 2013 Tuesday
Could Employers Use Immigrants to Avoid the Health Mandate?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 880 words
HIGHLIGHT: It has been reported that the new health insurance law combined with the immigration law passed by the Senate would reward employers for hiring illegal immigrants. But would it?
In a bid to win conservatives over to the cause of immigration reform, the authors of the Senate bill included a provision that would deny health benefits to illegal immigrants seeking to become legal. Now there is an argument making the rounds that this provision will encourage companies to replace American workers with those newly legalized immigrants.
The immigration reform bill that passed the Senate denies illegal immigrants who embark on the pathway to citizenship - the bill calls them registered provisional immigrants - access to the subsidies for purchasing health insurance available under the Affordable Care Act. Because the new law ties the penalties for employers who offer inadequate health insurance, or none at all, to the subsidies their workers receive, companies whose workers are ineligible for subsidies could avoid those penalties.
"Some employers would face no penalty for failing to provide such workers affordable health coverage," Jed Graham, a reporter for Investor's Business Daily, wrote in April. Mr. Graham called this "an incentive of up to $3,000 per year to hire a newly legalized immigrant over a U.S. citizen." Under the bill, these immigrants would not be entitled to subsidies until they received a green card, which would take 10 years.
Investor's Business Daily has been opposed to the health insurance overhaul, and ironically enough, this claim seems to have first been embraced by conservatives. But the argument has since made its way across the political spectrum: by June it cropped up in both the New Republic and Mother Jones. You're The Boss readers repeated the claim in comments to a recent post about small businesses and immigration.
Here's how it would work - and because the Affordable Care Act's employer mandate, like everything else about the health care bill, is mind-numbingly complex, so, too, would be such a scheme to circumvent it by hiring newly legal immigrants. The recently postponed mandate, which applies to businesses with at least 50 employees, basically works two ways. (Feel free to consult this handy chart published by the Kaiser Family Foundation.) First, if a company offers no insurance at all, and at least one employee buys individual insurance with a government subsidy, the company must pay a penalty. The penalty equals the total number of employees minus 30 multiplied by $2,000. A company with 50 employees, for example, would pay $40,000. But if this company managed to make sure that all of its lower-paid employees - the subsidies are available to anybody making less than 400 percent of the federal poverty level - were registered provisional immigrants, it would avoid the penalty altogether, because none of them could buy subsidized insurance.
If, on the other hand, the company offers insurance but it does not meet the health law's minimum standards, or some employees find it unaffordable, then employees are free to buy their own insurance. And for each employee who buys insurance with a taxpayer subsidy, the company must pay a $3,000 penalty - if 10 employees require subsidies, for example, the total penalty is $30,000. (This penalty is not as draconian as it might seem, because it is limited to the amount the company would pay if it offered no insurance at all.) So for every legal immigrant or citizen that a company offering sub-par health benefits replaced with a registered provisional immigrant, the company could save $3,000.
But how realistic is this? To skirt this law, the companies would have to out-and-out violate another: it is illegal to ask applicants about their immigration status - an employer can ask job candidates only if they are authorized to work in the United States.
And, frankly, it is a lot of effort. "Most employers want to focus on their business and not build these complicated schemes," said Alan Cohen, the chief strategy officer and co-founder of Liazon, which offers employers group health insurance through what it calls a private benefits exchange. But companies that did try this scheme, he added, would enter "a house of cards that can come down on you at any time. And it's not just the law itself. One little change in guidance and all of a sudden all that work you did, out the window.
"At the end of the day, offering employee benefits is all about attracting good employees. I think every business tries to attract and retain employees at some level. What's going to happen is people are just not going to work for people who scheme to harm their employees."
In any event, the prospect of employers ever having the opportunity to take advantage of these provisions seems increasingly remote. For one thing, not only has the administration delayed the effective date of the mandate for a year, but both conservatives and liberals have called for its repeal. And until House Republicans decide to take up the Senate bill, any discussion of registered provisional immigrants on a pathway to citizenship is going to remain academic.
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
Bakery Owner Talks About Coping With Health Insurance Changes
Should a Bakery With More Than 50 Employees Offer Health Insurance?
How Would Immigration Reform Affect Small Businesses?
The Challenges of Raising Prices and Competing With Online Retailers
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(Economix)
July 19, 2013 Friday
What Makes U.S. Health Insurance Exchanges So Complicated
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1325 words
HIGHLIGHT: Americans’ insistence on broad choices in health insurance raises both the cost and complexity of establishing insurance exchanges, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
There is much coverage and commentary on news Web sites about whether the health insurance exchanges called for in the Affordable Care Act will be ready by Oct. 1 for enrollment by individuals seeking health insurance in the nongroup market. Insurance bought there takes effect on Jan. 1. I sense that many of those commenting would like the exchanges to fail.
Why is setting up these exchanges so difficult? After all, they are not a novel invention. The eHealthInsurance.com Web site, for example, has since 1997 functioned as an electronic exchange for private health insurance products sold in the nongroup United States market.
That exchange and similar existing private exchanges, however, are not suitable models for the exchanges envisaged in the Affordable Care Act. They function merely as passive brokers for whatever policies private insurers under contract with them choose to list. It is up to consumers to pore over the fine print of any particular insurance contract listed on an exchange for a detailed description of coverage benefits, limitations and exclusions.
There have been many reports on how coverage gaps in the fine print of such policies can leave people who believe they have health insurance in serious financial distress once they fall ill. See, for example, an analysis by Consumer Reports.
More relevant as a model in this context might be the health insurance exchanges in several European countries that operate social health insurance systems with multiple competing private insurers - Germany, the Netherlands and Switzerland prominent among them.
Let us therefore pretend that we are residents of Switzerland and rummage around in a Swiss health insurance exchange.
All Swiss residents are required by federal statute to purchase insurance coverage for a common, comprehensive benefit package prescribed in the statute. Individuals buy that coverage on health insurance exchanges whose architecture is broken down by canton and that facilitate easy comparisons of the community-rated premiums charged by the competing private insurance carriers active in the individual's canton.
Individuals can purchase supplemental benefits - e.g., coverage for private rooms in hospitals or alternative medicine - from the same companies on the same exchanges. The premiums for these benefits, however, are medically underwritten, which means that they depend in part on the applicant's health status.
Private insurers in Switzerland are not allowed to earn profits on the common, comprehensive, social-insurance benefit package they cover, but they can earn profits on the supplemental benefits.
The Swiss company Comparis, a general insurance broker, among other exchanges operates one for health insurance, and it is available in English.
To receive premium quotes from competing insurers, one enters the postal code of one's residence (e.g., 3010 for a part of the city of Bern). One is also asked to identify one's current insurance carrier in a pop-up list of carriers serving the canton. As if I were a Swiss resident, I randomly clicked on "Publisana" from that list. (A new resident would click on "Relocating to Switzerland.")
Because basic benefits are standard across Switzerland, the only consumer choice with regard to the benefit package is the deductible, which can range from 300 to 2,500 Swiss francs. (At current exchange rates, a Swiss franc is about $1.06.)
At the bottom, one can choose comparisons among standard coverage, a gatekeeper model (with a general practitioner), health maintenance organizations and telemedicine (shown as Telmed). I recommend "standard," offering free choice of provider.
Click on "Continue," and up comes the comparison of premiums for one's chosen deductible for policies sold in one's canton. Monthly and annual premiums of the various insurers are shown, along with the savings one could achieve by switching insurers.
A click on "request quote" leads to a page offering supplementary insurance for various items. A click on the "i" in green provides information on each supplementary benefit. Note that generous maternity benefits are included in the basic coverage and one can opt for additional services. (European men do not seem to view being forced to pay for maternity care an affront. At least one critic of the Affordable Care Act in the United States, on the other hand, has denounced inclusion of maternity benefits among the basic benefits as "Obamacare's War on Men.")
Swiss insurance exchanges seem quite simple and user friendly. Presumably, no one needs the assist of an insurance navigator to work through this Web site.
So why can't the insurance exchanges under the Affordable Care Act be as simple as those in Switzerland? Why would it take almost three years to set up the American exchanges? And why will American buyers of health insurance need specially trained navigators to help them navigate these exchanges?
There are several reasons.
For one, the exchanges are but one small component of America's highly complex health insurance system and must be stitched smoothly onto its many facets - a challenge that would be just as demanding for anyone proposing to move toward universal health insurance coverage through private insurers, even in the absence of deliberate attempts to sabotage the effort.
Swiss exchanges do not determine the public subsidies to which lower-income Swiss residents are entitled. These subsidies are handled by a different, cantonal authority. Therefore the Swiss exchanges do not have to determine eligibility for insurance. By contrast, in the United States, state-based exchanges must coordinate with the Internal Revenue Service to determine eligibility for subsidies and their magnitude.
The American exchanges must also work with the state-administered Medicaid programs, to determine whether an applicant on the exchanges should be referred to Medicaid, and with small employers.
Furthermore, some American exchanges will be "active" - they will actually negotiate premiums with insurers.
Finally, the Swiss exchanges need to feature premiums only for exactly the same health benefits. Individuals have a choice only over the deductible in the policy. The Affordable Care Act does specify the basic benefits that must be covered, which each state can translate into its own basic benchmark package. There will be four levels of covered benefits (bronze, silver, gold and platinum) that are likely to differ mainly by the degree of cost-sharing (deductibles, co-payments and co-insurance). But some variation of covered services around the state benchmark package nevertheless will be possible within the same actuarial value of a policy, adding some complexity.
Benefit packages on the American exchanges will also vary by the degree of choice among providers that different policies permit. Presumably, the exchanges will have to ascertain the adequacy of the networks of providers attached to particular policies.
In short, comparing the various offerings on the American exchanges will not be nearly as simple as it is on the Swiss exchanges; hence the need for the specially trained navigators.
Americans insist on choice and pluralism among insurance products, enabling them to find coverage they believe will fit their personal needs. That choice, desirable though it may be, comes at a stiff price, with two dimensions.
First, it adds considerably to monetary outlays on administrative functions, which in the United States run about twice per capita what they are in other countries. And to make careful and responsible choices takes a great deal of a person's time.
The Path to Complexity on the Health Care Act
The New Economics of Part-Time Employment
Putting Off the Employer Mandate
Confusing the Public on the Affordable Care Act
'Premium Shock' and 'Premium Joy' Under the Affordable Care Act
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(Economix)
October 23, 2013 Wednesday
The Power of the Individual Mandate
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 851 words
HIGHLIGHT: Powerful incentives in the Affordable Care Act are likely to bring a sharp reduction in the number of working Americans who go without health insurance, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
If and when the Affordable Care Act is executed as planned, it will leave few members of working families uninsured.
About 31 million members of nonpoor working families are without health insurance (according to my calculations from the Census Bureau's current population survey). An important reason they do not have private health insurance coverage is that, in one way or another, they find it too expensive. Their employer may offer health insurance, but they decline coverage because the premiums are too much.
If their employer doesn't offer insurance, the uninsured workers are, judging from their behavior, unwilling to switch to an employer that does offer health insurance in exchange for lower cash pay (of course, finding such an employer may not be easy and may require a move across state lines, but that's my point: getting private insurance is costly).
The Affordable Care Act has at least two provisions to make insurance cheaper to workers who have so far been uninsured, compared with what employer insurance would have cost them in previous years, and these will take effect in the next couple of years (or whenever the federal government gets its systems running, whichever comes later).
The first provision is the "individual mandate penalty" for being uninsured, which will eventually reach the greater of 2.5 percent of husband-and-wife income, or $695 per uninsured family member (up to three, with uninsured children counting half, and the $695 indexed to inflation). Undocumented immigrants are not liable for the penalty.
The penalty effectively makes insurance cheaper because people can avoid it by getting insurance. In effect, all nonpoor legal residents pay the penalty, but people who purchase health insurance get their penalty applied toward their health insurance premiums.
The law's premium assistance tax credits are another provision that makes insurance cheaper, at least for uninsured nonpoor people living in households below 400 percent of the federal poverty line.
These two provisions are a potent combination - and might be reinforced by the prospect of Internal Revenue Service enforcement of fines due.
I estimate that nine million of those who would have been uninsured without the law will find their own health insurance to be free, or even better, in the sense that their penalty (in the years 2016 and beyond) for being uninsured exceeds the premium that they probably would pay on the law's new health insurance marketplaces (I use the Kaiser Family Foundation calculator to make these estimates because the marketplaces are not yet operational). As taxpayers, each of these families will be helping to pay for other people's health insurance; those taxes will be owed regardless of what the family decides about its own insurance.
Without the individual mandate, those nine million people might be tempted to remain uninsured.
Although the remaining 22 million nonpoor workers (and their dependents) will have to pay something to have health insurance, most of them will find insurance to be cheaper than it was before the Affordable Care Act. In addition to the nine million who will find insurance to be free (in the sense defined above), another 13 million will find insurance to be at least 25 percent cheaper than it was to get employer insurance before the law passed, and they are therefore more likely to purchase it.
The individual mandate is politically unpopular, and we don't yet know how vigorously the Internal Revenue Service will enforce it. The law precludes the I.R.S. from criminally prosecuting taxpayers who refuse to pay their penalty, and on this basis some observers have predicted that the I.R.S. will collect hardly any penalties. Others believe that the I.R.S. can get its penalty revenue if it tries hard enough.
After all, banks and other private-sector creditors cannot criminally prosecute either, yet they still manage to collect from most of their borrowers. Senator Tom Coburn, Republican of Oklahoma, explains how the I.R.S. can add penalties and interest to unpaid individual mandate penalties and establish a lien against the delinquent taxpayer's property so that, should the property be sold, sales proceeds can go toward paying the I.R.S. The I.R.S. can also press delinquent taxpayers for payment.
The Affordable Care Act prohibits the I.R.S. from filing a Notice of Federal Lien, which would give its lien priority over other liens, but, again, that makes the I.R.S.'s collection toolbox more like the toolbox that private-sector creditors have.
For all of these reasons, the individual mandate can be enforced and thereby help discourage millions of people from going without health insurance.
Health Care Inflation and the Arithmetic of Labor Taxes
Who Abandoned the Health Insurance Credit
What Makes U.S. Health Insurance Exchanges So Complicated
What Happens if You Don't Pay Your Taxes
Tax Withholding Still Controversial After 70 Years
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The New York Times
June 10, 2016 Friday
Late Edition - Final
Spirited Debate Over U.S. Health Care Costs Has Its Cheerleaders: Actuaries
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1419 words
DANVILLE, Pa. -- The Geisinger Health Plan, run by one of the nation's top-rated health care organizations, foresees medical costs increasing next year by 7.5 percent for people buying insurance under the Affordable Care Act.
So when Geisinger requested a rate increase of 40 percent for 2017, consumer advocates were amazed. And Kurt J. Wrobel, Geisinger's chief actuary, found himself, along with other members of his profession, in the middle of the health care wars still raging in this political year.
Actuaries normally toil far from the limelight, anonymous technicians stereotyped as dull and boring. But as they crunch the numbers for their Affordable Care Act business, their calculations are feeding a roaring national debate over insurance premiums, widely used to gauge the success of President Obama's health care law. Health plans around the country have just filed proposed rates for 2017. State insurance commissioners are still reviewing them.
But questions about the proposed increases are reverberating through the health care system and into the political campaign.
''Historical experience is the lifeblood of what we do,'' Mr. Wrobel said, in an interview at Geisinger's headquarters here. ''We take that experience, adjust it for the underlying growth of health costs and project it into the future so we can estimate the expected costs for a particular insurance policy.''
Such niceties may be lost in this scorching campaign season. ''There is panic and anger as health care costs explode!'' Donald J. Trump, the presumptive Republican presidential nominee, wrote in a recent Twitter post, seizing on increases of nearly 60 percent sought by Blue Cross and Blue Shield of Texas.
Obama administration officials are more sanguine. Consumers, they say, should not worry. Proposed rate increases are often reduced by state officials. Federal subsidies will generally rise along with premiums, offsetting much of the additional costs, and consumers can, in any event, switch to cheaper health plans next year.
But as they prepare for the fourth year of coverage under the Affordable Care Act, many insurers are struggling to find the best ways of providing care to their new customers. The giant UnitedHealth Group, having lost money on individual policies under the federal health law, is pulling out of many insurance exchanges next year. A number of health insurance cooperatives created under the law have shut down.
Geisinger is different. During debate on the 2010 health care law, Mr. Obama and members of Congress repeatedly hailed it as a model providing ''high-quality care at costs well below average,'' in the president's words.
Geisinger serves residents of rural central and northeast Pennsylvania, and its roots in the community are as deep as the coal mines that once flourished here.
Dr. David T. Feinberg, the president and chief executive of the Geisinger Health System, said its health plan was losing $30 million a year on coverage sold on the federal exchange in Pennsylvania. But leaving the market here would be unthinkable.
''For its shareholders, United made the right decision,'' Dr. Feinberg said, ''but we don't answer to shareholders. We answer to the nice people of Danville, Shamokin and Bloomsburg.''
It would be difficult to find a health plan more aligned with the goals of the federal law. The Obama administration recruited a former chief executive of the Geisinger Health Plan, Dr. Richard J. Gilfillan, to be the first director of the Center for Medicare and Medicaid Innovation, created by the health law to test ways to improve care and cut costs.
Geisinger has been a pioneer in the use of electronic health records and genomic medicine, recruiting 100,000 patients for DNA sequencing studies in the last two years. It has embraced ''pay for performance,'' offering a warranty for major surgical procedures and promising not to charge extra if complications occur.
But innovation has been no match for the actuarial surprises dealt out by the Affordable Care Act. Mr. Wrobel said Geisinger had simply underestimated how much care its new customers would need.
''Our rates for Medicare, Medicaid and employer-sponsored insurance have been relatively stable, but those products have to bear the cost of our losses on exchange business,'' Mr. Wrobel said.
Last October the Pennsylvania Insurance Department, headed by a former Obama administration official, approved a 20 percent increase in Geisinger's rates, about half of what the company had requested.
''But based on experience,'' Mr. Wrobel said, ''the 2016 premium rate is too low, so we want to correct it in 2017.''
Julia T. Philips, an award-winning actuary who worked 19 years for the state of Minnesota, said insurance regulators generally do not let a company make up for past losses with future rate increases.
''But regulators often allow companies to catch up,'' she said. ''If you assumed that claims would average $400 per member per month in 2015 and the actual cost was $440, you can use the higher number as a starting point in predicting claims costs for 2017.''
Obama administration officials suggest that insurance companies seeking big rate increases have been slow to adapt to the new law. But Geisinger executives welcome innovation, and they have celebrated the reduction in the number of uninsured under the Affordable Care Act.
Geisinger is not alone. The Pennsylvania Insurance Department says insurers have proposed premium increases averaging 23.6 percent for individual coverage for 2017.
''People with pre-existing conditions are now getting treatment,'' said Antoinette Kraus, the director of a statewide consumer group, the Pennsylvania Health Access Network, ''and it's more expensive because they were shut out of the market for many years.''
But, she added, ''we expect that they'll eventually become healthier, so we won't see these huge rate increases every year.''
Kevin J. Counihan, the chief executive of the federal insurance marketplace, acknowledged that ''pent-up demand for health care is greater than people expected and is lasting longer than expected.''
In April, before most insurers had filed their rate requests for 2017, the Obama administration began a campaign to play down their significance. ''Proposed rates aren't what consumers pay,'' the Department of Health and Human Services said. ''Most people receive tax credits and can buy a plan for less than $75 per month.''
Moreover, the administration says that the health law created a competitive market in which consumers can shop for the best deal. As evidence that this market is working, the administration boasts that more than 40 percent of returning consumers switched to different plans for 2016.
However, Mr. Wrobel said, such turnover is making it more difficult for insurers to predict costs. ''The whole point of what we do, the foundation of good health insurance,'' he said, ''is to develop long-term relationships with our members and to make long-term investments in their health. It's not like buying a book on Amazon.''
Besides, he said, substantial numbers of consumers do not receive subsidies. The Congressional Budget Office estimates that 12 million people will receive subsidies, in the form of tax credits, next year. But it says that an equal number -- three million on the exchanges and nine million buying insurance outside the exchanges -- will have to pay the full unsubsidized price.
''When we developed rates for 2014,'' Mr. Wrobel said, ''we had no historical data. It was basically an educated guess.''
Mr. Wrobel said rates were still being affected by a federal policy, adopted in late 2013, that allowed some people to keep and renew insurance that did not meet standards in the Affordable Care Act. ''Healthier people chose to keep their plans,'' he said, ''so the collective cost of care for people buying insurance on the exchange was higher than expected.''
Many insurers hope to profit from the Affordable Care Act, but for Geisinger, the calculus is a little different.
''Geisinger has been here for 100 years, and we expect to be here another hundred,'' Mr. Wrobel said. ''We are going to be taking care of the people in this community one way or another. So it's really important for this program to be financially stable and sustainable.''
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URL: http://www.nytimes.com/2016/06/10/us/health-insurance-affordable-care-act.html
LOAD-DATE: June 10, 2016
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GRAPHIC: PHOTOS: Kurt Wrobel, chief actuary at Geisinger Health Plan, at Geisinger Medical Center in Danville, Pa. He said the 2016 premium rate is too low, ''so we want to correct it in 2017.'' (PHOTOGRAPHS BY MARK MAKELA FOR THE NEW YORK TIMES)
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March 13, 2014 Thursday
Late Edition - Final
Health Mandate Won't Be Delayed, Sebelius Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 789 words
WASHINGTON -- Kathleen Sebelius, the secretary of health and human services, said Wednesday that the Obama administration would not extend the deadline for people to sign up for health insurance or delay the requirement for most Americans to have coverage.
And she declined to say whether the administration was still committed to its original goal of enrolling seven million people in private coverage through federal and state exchanges by March 31.
Testifying before the House Ways and Means Committee, Ms. Sebelius said categorically that the administration would not delay the ''individual mandate,'' under which most Americans must have insurance or pay a tax penalty. In addition, she said that officials would not extend the six-month open enrollment period, scheduled to end on March 31.
Ms. Sebelius reported Tuesday that 4.2 million people had selected health plans through the federal and state exchanges from October through February.
Representative James B. Renacci, Republican of Ohio, noted that the number of sign-ups was well short of the administration's original goal and asked, ''What do you now call success?''
Ms. Sebelius declined to reaffirm the goal of seven million and said she would define success as ''millions of people having affordable health care'' through private insurance and Medicaid.
The Affordable Care Act is already a success, she said, because the range of private health plans available to consumers is ''more robust'' than ever.
Representative Dave Camp, Republican of Michigan and chairman of the committee, opened the hearing with a barrage of questions and criticism for Ms. Sebelius.
''How much did the failed launch of the exchange cost taxpayers?'' Mr. Camp asked. ''How many people have actually paid a premium? How many previously uninsured Americans have signed up for Obamacare?''
Mr. Camp said: ''Increasingly, we must ask, 'When is the next delay or next administrative change in the law coming?' It seems that not a holiday goes by without a new announcement from the administration that delays some part of Obamacare.''
The senior Democrat on the committee, Representative Sander M. Levin of Michigan, said millions of Americans were benefiting from the law and its insurance marketplaces. But, he said, ''Republicans are so invested in making the Affordable Care Act a failure that they are blinded by the successes staring them in the face.''
However, a few Democrats also expressed disappointment and frustration at the way the health law was being carried out. ''So much of the original promise of the Affordable Care Act has been undermined by faulty implementation that has sometimes been indifferent to local concerns,'' said Representative Lloyd Doggett, Democrat of Texas.
''At best,'' Mr. Doggett said, ''less than 10 percent of exchange-eligible Texans have selected a plan. In other words, more than 90 percent of the people whom we wrote this law to get exchange coverage have not been covered.'' In parts of the state, he said, it is nearly impossible for consumers to obtain ''in-person assistance'' in selecting a health care plan.
So far, according to the latest data from the federal government, 295,000 people in Texas have selected private plans through the federal marketplace.
Ms. Sebelius said state laws and other barriers had made it hard for Texans to learn about and take advantage of the new insurance options. State officials in Texas, which has the highest uninsured rate of any state, rejected the expansion of Medicaid and declined to establish their own health insurance marketplace.
Representative Tom Reed, Republican of New York, noted that in a special congressional election in Florida this week the Democratic candidate defended the health care law but said it should be ''fixed.''
Ms. Sebelius said she was open to possible changes, but had not sent any draft legislation to Congress. However, she said, ''We have implemented a number of changes in the way the law was written to ease the transition into the marketplace'' for consumers, insurers and employers.
Other Republicans on the committee focused their criticism on the administration's handling of the rollout.
Representative Tom Price, Republican of Georgia, expressed disbelief when Ms. Sebelius said she did not know how many of the 4.2 million people selecting health plans had paid the premiums required to complete their enrollment. She said the data would be available when the government finished building a ''fully automated financial system'' for the exchanges.
Representative Diane Black, Republican of Tennessee, said that, with so many changes and delays by the administration, her constituents were ''really confused about what this law does and doesn't do and what applies to them.''
URL: http://www.nytimes.com/2014/03/13/us/politics/no-plan-to-extend-health-care-enrollment-deadline-or-delay-mandate.html
LOAD-DATE: March 13, 2014
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GRAPHIC: PHOTOS: The House Ways and Means Committee, including Representatives Paul D. Ryan of Wisconsin, left, and Kevin Brady of Texas, questioned Kathleen Sebelius, the secretary of health and human services, on Wednesday about the Affordable Care Act. (PHOTOGRAPHS BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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The New York Times
April 7, 2017 Friday
Late Edition - Final
G.O.P. Adds $15 Billion to Health Bill to Aid Sickest
BYLINE: By ROBERT PEAR; Reed Abelson contributed reporting from New York.
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 761 words
WASHINGTON -- Under intense pressure from President Trump, House Republicans took a small step Thursday to revive legislation to dismantle the Affordable Care Act, adding a $15 billion fund to help insurers pay claims for their sickest customers.
Speaker Paul D. Ryan orchestrated a broad show of Republican support for the proposal, conceived as an amendment to the repeal bill that collapsed on the House floor two weeks ago. But Republicans said they still did not have enough votes to pass the bill, and with the House now on a two-week spring break, time is running out for their planned quick-strike repeal of President Barack Obama's health care law.
Even so, Republicans said the amendment could help heal divisions in their conference and show progress to an impatient president, still smarting from a loss in his first showdown with Congress.
By a party-line vote of 9 to 2, the House Rules Committee on Thursday gave its blessing to the proposal, devised by Representatives Gary Palmer of Alabama and David Schweikert of Arizona, both members of the conservative House Freedom Caucus.
Mr. Palmer said the ''risk-sharing program'' would lower premiums by sparing insurers some costs. With lower prices, he said, more people would buy insurance.
He estimated that it would reduce the number of uninsured Americans by 1.2 million to 2.2 million. However, those gains would be dwarfed by other parts of the repeal bill, which the nonpartisan Congressional Budget Office says would result in 24 million more uninsured people compared with projections under current law.
Mr. Ryan said the new program would also help stabilize insurance markets. ''One of the concerns we have is that insurers are leaving left and right, and people are down to, like, one choice, and in some cases no choices,'' he said.
In the latest sign of turmoil, Aetna announced on Thursday that it would leave Iowa's insurance exchange in 2018 because of ''financial risk and an uncertain outlook for the marketplace.'' That followed Monday's announcement by Wellmark Blue Cross and Blue Shield, Iowa's largest carrier, that it would not sell Affordable Care Act plans there next year.
This leaves a single insurer for the bulk of the state. ''We're deeply troubled by the angst and concern the Affordable Care Act is causing in Iowa,'' the state's insurance commissioner, Doug Ommen, said in a statement.
Under the latest Republican proposal, patients with high-cost conditions like metastatic cancer and AIDS would not be segregated in a separate insurance pool, but their insurers could receive extra payments, as the government would cover a share of claims exceeding a level specified by federal health officials.
Reactions to the proposal showed the political challenges facing Republicans.
Representative Nancy Pelosi of California, the House Democratic leader, said it did nothing to improve the legislation, which she called a ''horrible, monstrous bill.''
And Representative Louie Gohmert, Republican of Texas, complained that the proposal gave ''more power to the federal government to dictate what states have to do to get more money.''
But the White House continues to press for at least the appearance of action. House Republicans took the repeal bill to the floor on March 24 in response to an ultimatum from Mr. Trump, and the president demanded action again this week, just as House members were about to leave town.
''Who's running this place?'' Representative Alcee L. Hastings, Democrat of Florida, asked. ''Is it the speaker, or is it the president? Are we letting the president tell us which amendment to report and when to report it?''
Mr. Palmer said his proposal was modeled on a program in Maine that reimbursed insurers for 90 percent of certain claims from $7,500 to $32,500 a year, and the full amount of claims past that.
Representative Tom MacArthur of New Jersey, a moderate Republican, said ''the beauty of this proposal'' was that it would be invisible to consumers with high-cost conditions. ''They would be treated like everyone else, with respect,'' he said, ''and the high dollar amount of their claims would not result in premiums going up for everyone else.''
But the earliest Congress could get to the measure is April 25, when lawmakers return. And at that point, they will have just days to pass legislation to fund the government through September, and will then begin work on a budget for the fiscal year that starts Oct. 1.
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URL: http://www.nytimes.com/2017/04/06/us/politics/health-care-affordable-care-act-house.html
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December 11, 2016 Sunday
Late Edition - Final
Should I Lie to Get Affordable Health Insurance?
BYLINE: By HILLARY ROSNER.
Hillary Rosner is a freelance journalist who reports about the environment.
SECTION: Section SR; Column 0; Sunday Review Desk; OPINION; Pg. 3
LENGTH: 1335 words
Boulder, Colo. -- HERE'S an ethical dilemma. If you could save your family more than $8,000 next year simply by signing a statement affirming belief in principles you find repugnant, would you?
It sounds absurd. But in fact that's the position I'm in this week, thanks to a loophole in the Patient Protection and Affordable Care Act, otherwise known as Obamacare. My health insurance poses a financial hardship to my family. All I have to do to lower my yearly bills by thousands of dollars is use my John Hancock to denounce gay marriage and a woman's right to control her reproductive destiny.
By Dec. 15, like many Americans, I need to choose a new health insurance plan for 2017. I am a freelance journalist and editor. My husband runs a small business that pays him a salary but no benefits. We are among the millions of Americans who, under the Affordable Care Act, buy individual insurance through an increasingly expensive and inadequate marketplace. Since the law went into effect, monthly premiums for my family of three have already more than doubled, from $450 a month to $930. (In Colorado, my home state, 2017 rates are on average 20 percent higher than they were in 2016; in some counties that number is 40 percent.) On top of that, high deductibles mean we pay for nearly everything ourselves. In 2016, between monthly premiums and out-of-pocket costs, we've spent roughly $20,000 on health care.
Our new plan, the fourth in four years, is being discontinued, so we must again seek new insurance. We don't qualify for federal subsidies. I've got six months of 2015 insurance premiums accruing interest on a credit card, and a $4,200 bill for a four-hour emergency room visit sits menacingly on my desk. The number of insurers offering individual plans in Colorado, as in many other states, has dwindled; there are now only three companies -- Anthem, Cigna and Kaiser -- left in our ZIP code. (In 14 Colorado counties, there is only one provider offering plans.) Only one of our longtime doctors participates in any of these 2017 A.C.A.-plan networks.
I support the Affordable Care Act. Before it took effect, my husband was once denied coverage on the grounds that he'd seen a doctor for a sinus infection; I was charged hundreds of dollars above the quoted rate because of a long-ago surgery with no lasting health impacts. I know people whose lives the Affordable Care Act has transformed, friends with pre-existing conditions that had made them uninsurable but who now can get the coverage they need. My support for the law comes from a belief that access to affordable health care should be an undeniable right. But the battle to get it passed produced a deeply, perhaps fatally, flawed law -- and on a personal level, my quality of life has declined under the A.C.A.
There are now a growing number of theoretically less expensive health care options that don't comply with the Affordable Care Act. I could, for instance, join a local membership-based primary care provider clinic -- around $200 a month for a family of three -- and combine it with a similarly priced catastrophic-coverage plan. But these options still leave gaps in your coverage, and subject you to a fine for not carrying proper insurance -- up to 2.5 percent of your adjusted gross income.
There is, though, one more option available to me. For only $500 a month -- a saving of $8,400 a year in premiums over the Anthem plan we are considering -- I could purchase coverage through a ''faith-based plan'' called Altrua HealthShare. Officially known as ''health care sharing ministries,'' such plans are not, strictly speaking, insurance. According to the Alliance of Health Sharing Ministries, ''The purpose of the ministry is simply to organize other people who voluntarily choose to help fellow members pay their medical bills in keeping with biblical commands to 'share one another's burdens.' ''
But in practice, the ministries serve much the same function as insurance. Members pay a monthly contribution, they are subject to an annual deductible (in this case, $1,000 per person) and their doctor submits a claim and is reimbursed by the plan.
Faith-based plans do not adhere to the same rules as Obamacare insurance plans. They don't have to pay for preventive care, they may not insure smokers, they may not cover pre-existing conditions, and they may deny you admission based on your weight. If you are a 5-foot-6 woman and weigh more than 230 pounds, for instance, Altrua HealthShare won't offer you membership. Unlike the other non-A.C.A.-compliant options, though, health care sharing ministries are actually exempt from the law. (These organizations have to meet certain requirements, and must have been in existence continuously since 1999.) That means if you sign up for one, you aren't subject to the fines.
While some health sharing ministries require membership in a Christian congregation, Altrua HealthShare does not. My family's doctors all participate in its extensive network. According to its guidelines, membership ''is based on a religious tradition of mutual aid, neighborly assistance and burden sharing.'' Sounds promising. Membership, Altrua's brochure continues, ''is specifically tailored for individuals who maintain a healthy lifestyle, make responsible choices in regards to health and care, and believe in helping others.'' I bike, hike and practice yoga; I'm a longtime vegetarian; I've never smoked. And who doesn't believe in helping others?
Here's the catch. In order to join, you have to agree to a ''statement of standards.'' Among the list of seven principles are these three: ''According to the Word of God, sexual relations outside the bond of marriage is morally wrong.'' ''Marriage is a bond between a man and woman only.'' ''Abortion is wrong, except in a life-threatening situation to the mother.''
I disagree with each of these. And the last I checked, premarital sex, same-sex marriage and abortion were legal in the United States. Still, I considered consenting to the ''standards'' for the sake of my family's financial situation. Imagine if we could put money away for college tuition, or pay down our credit card debt, instead of sending thousands to a giant corporation. What if I swallowed my principles and sent a contribution to Planned Parenthood as penance?
But in the end, I simply couldn't do it. Much like many of these ministries' members, I believe certain principles are sacred. (Altrua won't pay maternity benefits if the pregnancy arose through ''adultery or fornication by the member.'') For those on the religious right, their beliefs grant them exemption from federal law, and access to decent affordable health care. Unfortunately, there's no such loophole for clean-living, charitable nonbelievers.
So next week, I will sign up for a plan that costs nearly $1,200 a month and that will still pay for next to none of my family's medical needs. I will have to part ways with the O.B. practice whose doctors saw me through a complicated pregnancy and delivered my son healthy. Because I hold one set of beliefs about right and wrong, I am subject to federal law. If I subscribed to a different set of morals, I would be exempt from its clutches.
Roughly 625,000 people belonged to health sharing ministries as of September; that number is sure to rise as people like me balk at their diminishing options. As Republicans grapple with the Affordable Care Act, it would be wise for them to keep in mind that, like it or not, America is composed of people with different backgrounds, ethnicities and beliefs. The answer is not to repeal the law, which could result in more than 23 million Americans losing their coverage. The answer is to find solutions that allow all working families to find affordable health care that doesn't demand choosing between their ethics and their ability to provide for their children.
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URL: http://www.nytimes.com/2016/12/10/opinion/sunday/should-i-lie-about-my-beliefs-to-get-health-insurance.html
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October 30, 2015 Friday
Late Edition - Final
Groups Want Exchange to Register Voters, Too
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 989 words
WASHINGTON -- When the Affordable Care Act's new enrollment season begins next month, people seeking health insurance through the online federal exchange will also be offered something they may not expect: a chance to register to vote.
But voting rights groups say the offer -- a link to a voter registration form that they can print and mail, deep inside the application for health coverage -- does not go far enough. This week, the groups accused the Obama administration of violating federal law by not doing more to ensure opportunities for voter registration through the exchange, HealthCare.gov, which serves 38 states.
In a letter to President Obama, the groups said that in contrast, most of the 13 state-based insurance exchanges have worked to comply with the National Voter Registration Act. The act, also known as the ''motor voter'' law, requires states to offer voter registration to people applying for a driver's license or public assistance.
''This is an important voting rights issue that can no longer be ignored,'' wrote the groups, which include the League of Women Voters, Project Vote and Demos, a liberal think tank.
Some voting rights experts are not certain their claim would hold up in court. At issue is whether the federal exchange is subject to the voter registration law because it is providing a service on behalf of the states it operates in.
''It's an interesting, creative argument,'' said Richard L. Hasen, a law professor at the University of California, Irvine. ''I just don't know if the courts will buy it or not.''
The voting rights groups say that among other things, the federal exchange should be offering to help applicants complete a voter registration form. Although many applicants use the exchange independently, others turn to its call center or to ''navigator'' groups that have federal grants to help people apply for coverage.
''The navigators aren't receiving any training or direction that they have to offer voter registration services,'' said Jenn Rolnick Borchetta, senior counsel at Demos.
Navigators in several states that use the federal exchange said the voter registration link was easy to miss in the online application for health coverage and many navigators do not focus on it while they are helping clients.
''I'd suspect not many people have used it,'' said Elizabeth Colvin, director of Insure Central Texas, a navigator group in Austin.
Michele Johnson, the executive director of the Tennessee Justice Center, a health care advocacy group in Nashville, said many navigators there ''never saw'' the question about voter registration while helping people sign up for health coverage. Others, she said, feared the question and link to a voter registration form were ''too political to mention,'' especially in Republican-controlled states like Tennessee where most elected officials oppose the Affordable Care Act.
''Anxiety on the part of navigators,'' Ms. Borchetta said, ''could be addressed by the federal government clearly saying what their responsibilities are under the law.''
A spokesman for the Centers for Medicare and Medicaid Services, which oversees the federal exchange, said the Obama administration ''strongly supports the goals of the National Voter Registration Act and is committed to enforcing its requirements, as applicable.''
The spokesman, Aaron Albright, would not comment on whether the administration believed the law was applicable to the federal exchange.
Republicans have spoken out against allowing voter registration through the Affordable Care Act exchanges, calling it inappropriate. Representative Charles W. Boustany Jr. of Louisiana, who complained about it to the Department of Health and Human Services before the exchanges opened in 2013, said on Thursday, ''HealthCare.gov was never intended to be a voter registration tool, just as state secretaries of state websites aren't used for signing up for health care.''
Mr. Hasen said that given the many battles the Obama administration has fought with Republicans over the Affordable Care Act, it might prefer letting a court decide whether the federal exchange has to comply with the voter registration law.
''The federal exchange tends to serve more Republican states,'' he said. ''This would be a way of potentially registering more Democratic voters there. So it's politically easier for an administration that's always accused of trying to expand federal power to have a court make this decision.''
State-based exchanges, which are mostly in heavily Democratic states, have slowly improved their compliance with the voter registration law, said Sarah Brannon, the director of the government agency voter registration program at Project Vote. Some, including California and New York, now train navigators and call center operators in how to handle the voter registration option during the enrollment process. Others have yet to offer voter registration through their exchange but are working on it, Ms. Brannon said.
The voting rights groups said that Ohio, which uses the federal exchange, had had no increase in the number of voter registrations from public assistance clients since the state expanded Medicaid under the Affordable Care Act, despite a sharp increase in the number of people applying for Medicaid benefits. Many people now apply for Medicaid, as well as subsidized private insurance, through the exchanges.
Ms. Brannon said the groups had been asking the administration to bring the federal exchange into compliance with the voter registration law for two years. Now that the Supreme Court has ruled that people in states that use the federal exchange can continue receiving health insurance subsidies, she said, the administration has no excuse not to do so. As for whether the federal exchange is legally required to comply with the law, Ms. Brannon said, ''It is a novel question, but we think the answer is very clear.''
URL: http://www.nytimes.com/2015/10/30/us/groups-want-federal-health-exchange-to-register-voters-too.html
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November 25, 2014 Tuesday
Schumer Calls Passing Health Act in 2010 a Political Mistake
BYLINE: JEREMY W. PETERS
SECTION: US; politics
LENGTH: 269 words
HIGHLIGHT: Senator Charles E. Schumer said Tuesday that it was a political mistake to pass the Affordable Care Act in 2010 because voters at the time were looking for relief from the recession — not universal health care.
One of the Senate's top Democrats said Tuesday that it was a political mistake to pass the Affordable Care Act in 2010, because voters at the time were looking for relief from the recession - not universal health care.
In remarks at the National Press Club, Senator Charles E. Schumer of New York said Democrats should have built on the stimulus package that passed Congress and used it to create programs to help middle-class Americans.
"Unfortunately, Democrats blew the opportunity the American people gave them," Mr. Schumer said, according to his prepared remarks. "We took their mandate and put all of our focus on the wrong problem - health care reform."
Mr. Schumer's calculus could seem coldly political. He points out that only a third of the uninsured population is even registered to vote. "To aim a huge change in mandate at such a small percentage of the electorate made no political sense," he said. "So when Democrats focused on health care, the average middle-class person thought 'the Democrats are not paying enough attention to me.'"
Republicans, he added, were able to exploit a sense among voters that Democrats were interested in creating new government programs that did not benefit them, helping to spawn the Tea Party movement.
"Republicans and the anti-government Tea Party filled that vacuum and spent 2010 convincing the average American that not only did Obamacare not work for them, not only would a parade of horribles emerge," he said, "but they turned Obamacare into a general metaphor and falsely convinced the electorate that government couldn't work anywhere."
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The New York Times
February 4, 2015 Wednesday
Late Edition - Final
House G.O.P. Again Votes to Repeal Health Care Law
BYLINE: By ROBERT PEAR; Julie Hirschfeld Davis contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 856 words
WASHINGTON -- The House passed a bill on Tuesday to repeal the Affordable Care Act for the first time in the new Congress, but Democrats appeared to show more zeal in defending the law than Republicans did in trying to get rid of it.
The measure goes now to the Senate, where the majority leader, Mitch McConnell, Republican of Kentucky, has said that the chamber will vote on legislation repealing the health law but has not announced a schedule.
Republicans in both chambers are divided over how to replace the law and how to respond if the Supreme Court upholds a challenge to insurance subsidies now being provided to millions of people under the law.
The House vote, 239 to 186, generally followed party lines. No Democrats voted for repeal. Three Republicans -- Representatives Robert Dold of Illinois, John Katko of upstate New York and Bruce Poliquin of Maine -- voted against the bill.
Despite an explicit veto threat from President Obama, Republicans said the vote on Tuesday was necessary to give new House members a chance to take a stand on the health law, which most Republicans had campaigned against. Freshman Republicans like Representatives Jody Hice of Georgia and Mia Love of Utah were among the most outspoken critics of the law on Tuesday.
Democrats said it was the 56th time since 2011 that the House had voted to repeal or undermine some or all of the law, which was adopted in 2010 without any Republican votes.
This time the repeal vote was different because millions of Americans have gained coverage through provisions of the law that expanded eligibility for Medicaid and subsidized private insurance for low- and middle-income people.
The chief sponsor of the repeal bill, Representative Bradley Byrne, Republican of Alabama, said opinion polls showed that a majority of Americans had unfavorable views of the law.
''I don't believe Obamacare can be fixed through piecemeal reforms,'' Mr. Byrne said. ''The only way to get rid of this harmful law is to repeal Obamacare in its entirety.''
Republicans said the law was driving up insurance premiums, burdening consumers with high out-of-pocket costs and leading some employers to cut back workers' hours so that employers would not have to pay for their coverage.
Representative Frank Pallone Jr., Democrat of New Jersey, said the vote was ''a complete waste of time'' because Mr. Obama would reject the bill and Congress could not override his veto.
Representative Nancy Pelosi of California, the House Democratic leader, called the bill frivolous.
''Republicans,'' she said, ''are baying at the moon. Instead of proposing any good suggestions they may have to improve the Affordable Care Act, they are baying at the moon.''
Just moments before the House began its debate, Mr. Obama met at the White House with 10 people who he said had benefited from the health care law.
''This is working not just as intended, but better than intended,'' Mr. Obama said. Why, he asked, was it such a priority for Republicans in Congress to take insurance away from cancer patients and others who were benefiting from the law?
Representative Mike Kelly, Republican of Pennsylvania, angrily disputed the suggestion that ''somehow we are taking something from somebody.''
''It's not the Republican Party that disapproves of the Affordable Care Act,'' Mr. Kelly said. ''It's the American people.''
Democrats relished the fight, citing tangible evidence that the law was working.
''Today we've gone back to the Republicans' old songbook -- yet another vote to repeal Obamacare,'' said Representative Jan Schakowsky, Democrat of Illinois. ''But let me warn them. They do this at their peril. Tens of millions of Americans, many insured for the first time, and others who can finally afford insurance will not give it up without a fight. The war against Obamacare is over, and Obamacare has won.''
The bill directs four House committees to report legislation to replace the Affordable Care Act.
Representative Tom Cole, Republican of Oklahoma, acknowledged that ''there has not been a unified Republican position'' on how to replace the health care law or respond if the Supreme Court upholds the challenge to subsidies in states using the federal insurance exchange.
Until now, Mr. Cole said, House Republicans did not have to specify an alternative to the 2010 health law because ''we knew it would not get through the Senate'' when Democrats controlled that chamber.
If the Supreme Court rules in favor of plaintiffs challenging the subsidies -- a decision is expected this year -- ''it will destroy health insurance exchanges in 30-odd states in the blink of an eye,'' Mr. Cole said, adding that Republicans needed to be prepared for that possibility.
Republicans have dozens of proposals to change the health law, but in describing their plans on Tuesday, they stuck mostly to general principles.
''House Republicans are developing patient-centered solutions, which preserve personal freedom, expand choice and allow people to keep the doctor and health insurance plan they like and trust,'' said Representative Tom Graves, Republican of Georgia.
URL: http://www.nytimes.com/2015/02/04/us/politics/house-gop-again-votes-to-repeal-health-care-law.html
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GRAPHIC: PHOTO: Speaker John A. Boehner with Representative Kevin McCarthy, left, the majority leader, before a House vote Tuesday on repealing the Affordable Care Act. Three Republicans voted against it. (PHOTOGRAPH BY JABIN BOTSFORD/THE NEW YORK TIMES)
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April 16, 2014 Wednesday
Late Edition - Final
Census Changes Complicate Tally of Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1142 words
WASHINGTON -- The Census Bureau, the authoritative source of health insurance data for more than three decades, is changing its annual survey so thoroughly that it will be difficult to measure the effects of President Obama's health care law in the next report, due this fall, census officials said.
The changes are intended to improve the accuracy of the survey, being conducted this month in interviews with tens of thousands of households around the country. But the new questions are so different that the findings will not be comparable, the officials said.
An internal Census Bureau document said that the new questionnaire included a ''total revision to health insurance questions'' and, in a test last year, produced lower estimates of the uninsured. Thus, officials said, it will be difficult to say how much of any change is attributable to the Affordable Care Act and how much to the use of a new survey instrument.
''We are expecting much lower numbers just because of the questions and how they are asked,'' said Brett J. O'Hara, chief of the health statistics branch at the Census Bureau.
With the new questions, ''it is likely that the Census Bureau will decide that there is a break in series for the health insurance estimates,'' says another agency document describing the changes. This ''break in trend'' will complicate efforts to trace the impact of the Affordable Care Act, it said.
A major goal of the law is to increase the number of people with health insurance. The White House reported that 7.5 million people signed up for private health plans on the new insurance exchanges and that enrollment in Medicaid increased by three million since October. But the administration has been unable to say how many of the people gaining coverage were previously uninsured or had policies canceled, so the net increase in coverage is unclear.
Health policy experts and politicians had been assuming that the Census Bureau would help answer those questions when it issued its report on income, poverty and health insurance, based on the Current Population Survey. The annual report shows the number of people with various kinds of health insurance and the number of uninsured for the nation and for each state.
Several recent private polls, including one by the Gallup organization, suggest that the number of uninsured is indeed declining, because of the Affordable Care Act and improvements in the economy.
Tara McGuinness, a White House spokeswoman, said the changes in the questionnaire would ''make it easier to measure the impact of the Affordable Care Act because it will be possible to compare data from 2013 and 2014.'' But officials said that the data for this year would not ordinarily be available until September 2015, and that the data for 2013 and 2014 would not be directly comparable with the long series of data for prior years.
Census officials and researchers have long expressed concerns about the old version of insurance questions in the Current Population Survey, and for more than a decade the agency has been trying to make it more accurate.
The questionnaire traditionally used by the Census Bureau provides an ''inflated estimate of the uninsured'' and is prone to ''measurement errors,'' said a working paper by statisticians and demographers at the agency.
In the test last year, the percentage of people without health insurance was 10.6 percent when interviewers used the new questionnaire, compared with 12.5 percent using the old version. Researchers said that they had found a similar pattern in the data for different age, race and ethnic groups.
In addition, ''the percentage of people with private coverage was statistically higher'' when the bureau tested the new questionnaire, the working paper said. For reasons that are not clear, people were less likely to respond when interviewers used the new questionnaire.
Another Census Bureau paper said ''it is coincidental and unfortunate timing'' that the survey was overhauled just before major provisions of the health care law took effect. ''Ideally,'' it said, ''the redesign would have had at least a few years to gather base line and trend data.''
The old questionnaire asked consumers if they had various types of coverage at any time in the prior year. The new survey asks if they have insurance at the time of the interview -- in February, March or April -- then uses follow-up questions to find out when that coverage began and what months it was in effect. Using this technique, census officials believe they will be able to reconstruct the history of coverage month by month over a period of about 15 months.
However, Mr. O'Hara of the Census Bureau said the agency was not planning to release coverage data from early this year in its next report. Agency officials want to assess the reliability of the monthly data, being collected this year for the first time.
The White House is always looking for evidence to show the benefits of the health law, which is an issue in many of this year's midterm elections. The Department of Health and Human Services and the White House Council of Economic Advisers requested several of the new questions, and the White House Office of Management and Budget approved the new questionnaire. But the decision to make fundamental changes in the survey was driven by technical experts at the Census Bureau, and members of Congress have not focused on it or suggested political motives.
The new survey was conceived, in part, to reduce a kind of bias or confusion in the old survey. When asked about their insurance arrangements in the prior year, people tended to give answers about their coverage at the time of the interview -- forgetting, for example, if they had Medicaid for a few months early in the prior year.
People are continually moving on and off Medicaid rolls. The number of people who say in surveys that they have Medicaid coverage is almost always lower than the enrollment figures reported by federal and state agencies that administer the program.
The new survey asks people if they have coverage through an exchange, if it has premiums and if the premiums are subsidized.
Census Bureau research in Massachusetts found that consumers ''inevitably conflate Medicaid and the subsidized exchange.'' And many people with subsidized private insurance, purchased on the exchange, said they were receiving coverage from the government or the state.
Such perceptions are understandable. ''Exchange coverage is a hybrid, partly private and partly government,'' said Joanne Pascale, a Census Bureau researcher who helped develop the new questionnaire.
Kathleen Thiede Call, a professor at the University of Minnesota who was consulted by the Census Bureau, said: ''I am excited about the redesign of the survey. For the first time, we will be able to look at monthly changes in coverage over a 14- or 15-month period.''
URL: http://www.nytimes.com/2014/04/16/us/politics/census-survey-revisions-mask-health-law-effects.html
LOAD-DATE: April 16, 2014
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GRAPHIC: PHOTO: A Census survey may not tally all Affordable Care Act enrollees, like Natalia Pollack of New York, aided by Carlos Tapia. (PHOTOGRAPH BY MIKE SEGAR/REUTERS)
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June 10, 2015 Wednesday
Late Edition - Final
Saving Affordable Health Insurance
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 707 words
The Affordable Care Act, which has helped millions of people get health care, is now fully woven into the nation's social fabric. As President Obama said Tuesday, there is something ''deeply cynical about the ceaseless, endless, partisan attempts'' to roll back the progress already made.
His remarks at a forum of the Catholic Health Association come only weeks before the Supreme Court is expected to issue a ruling that could, if the administration loses, eliminate federal tax subsidies in 34 states that have made it possible for millions of Americans to buy health insurance. Mr. Obama was right when he said on Monday that the court probably shouldn't have even taken the case. Unfortunately it did, and no one can predict how the deeply divided court will rule.
The administration claims to have no contingency plan should the subsidies be invalidated. But some states, fearing the worst, are beginning to consider options, none of which look easy to carry out.
The Affordable Care Act provides subsidies in every state for low-income people who earn too much to qualify for Medicaid, the health program for the poor. Opponents of the act have seized on careless wording in the law to argue that subsidies should be available only in states that have established their own health insurance exchanges but not in states that chose to use HealthCare.gov, the federal government's exchange. That defies common sense and the understanding of all those who passed the law in 2010. There was never any question that the A.C.A. subsidies would be available on exchanges in all the states.
There is an easy solution for the problem. Congress could pass a one-sentence law clarifying that subsidies will be available on all the exchanges. That's what polls show Americans want. But congressional Republicans are not about to do anything realistic to help millions of people keep their health coverage, and are bent on destroying the law that made coverage possible.
As Mr. Obama noted, since he signed the law in March 2010, more than 16 million uninsured Americans have been covered, driving the uninsured rate to the lowest level ever recorded. Americans can no longer be denied coverage because of pre-existing conditions. Health care prices and employer premiums have been rising at very low rates. There are no more annual or lifetime limits on how much insurers have to pay for care. And as for the claim by Republicans that the program is a ''job killer,'' the nation has experienced 63 straight months of private-sector job growth, starting the month the act was passed.
It would be tragic at this point to reverse course and put millions of Americans at risk of disease and death from inadequate heath care or potential bankruptcy from inability to pay staggeringly high medical bills while disrupting insurance markets that depend on large enrollments to stabilize prices.
If the court negates the subsidies on federal exchanges, any rescue effort would have to conform with the language of the court's ruling. The court would presumably tell the Internal Revenue Service, which interpreted the law to mean that subsidies would be available in all states, to redefine what constitutes an exchange ''established by the state'' and thus one that is eligible for the subsidies.
There has been some loose talk that it could be done readily -- by declaring that what was previously a federally run exchange is now a state-run exchange. But experts who have looked closely at the options say converting would not be easy. While the administration would presumably try to make the transition as smooth as possible, the states that established their own exchanges in the past did so with hundreds of millions in federal grants that are no longer available and lots of technical help from the federal government. They also had time to get the job done.
A long analysis in the Yale Law Journal concluded that there are no quick, obvious remedies. To have any chance of reducing the damage, states need to start planning immediately. Among the states at risk, only Pennsylvania and Delaware have signaled intentions to do so.
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(You're the Boss)
November 3, 2014 Monday
A Builder Swears He'll Stay at 49 Employees to Avoid the Mandate. Unless He Grows.
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 898 words
HIGHLIGHT: The comment, an owner says, was an expression of his frustration with just how complex the Affordable Care Act is and how the resulting confusion has paralyzed his company.
Todd Hawkins is a Virginia home builder who insists that the big plans he has for his business are not so big that they will put him in the path of the Affordable Care Act. That, anyway, is what he told You're the Boss readers when he commented on a recent post about determining whether a company is subject to the law's employer mandate. "I can promise we won't go over 49 employees, so A.C.A. will affect employment, at least by one company," he wrote. "Mine."
But Mr. Hawkins told a different story when I contacted him a few days later to talk about his comment. "Next year," he said, if he and his partner's new idea works out, "that's when we'll run into the A.C.A." He has 21 employees now.
Mr. Hawkins and his partner, Jonathan Fishbeck, met after they had both been hit hard by the recession. Mr. Hawkins had been laid off from his job as a salesman, he said, after it had become clear that most of his customers were going under. Mr. Fishbeck was a builder on borrowed time as clients started canceling their contracts. The two became friendly, and Mr. Hawkins urged Mr. Fishbeck to change his company's name, suggesting BuilderFish. And soon, though Mr. Hawkins knew nothing about construction, they joined forces.
Since 2010, they have been building luxury homes in Washington's Virginia suburbs. Besides those 21 employees, the company makes use of perhaps 100 or more subcontractors that Mr. Hawkins calls "teammates." (Lawyers warn that businesses like BuilderFish that rely on subcontractors ought to tread carefully: They could find themselves subject to the mandate - and liable for penalties, even retroactively - should the Internal Revenue Service conclude that the subcontractors are actually misclassified employees. "We are very conscious of the trouble we could get in," Mr. Hawkins said. "We've never done anything without our lawyer's advice on that.")
"We have been thinking about and dealing with the Affordable Care Act since we first heard about it," said Mr. Hawkins, who added that he and his partner have wanted to offer insurance "from Day 1. We've wanted to insure ourselves." But when they've looked at the math - first late last year and then again early this year - and repriced a completed project with and without health insurance, they concluded they could not absorb the overhead. "We're already premium priced," Mr. Hawkins said.
Instead, the company gives employees a lump sum they can use to purchase insurance if they so choose. (Mr. Hawkins would not elaborate on any of the calculations they've made to inform their thinking so far on offering health insurance - he said that nobody at the company could remember the exact figures.) But this arrangement may not last.
Mr. Hawkins and Mr. Fishbeck aim to transform BuilderFish from a company that, in addition to designing and building large houses and estates, manages every aspect of the finished property for the new homeowners. "You'll have one BuilderFish rep that takes care of everything," he said, from landscaping and maintenance to hiring household staff. The company has made a considerable investment in developing computer software to help manage the operation.
But without health insurance, he said, "you can't attract the best employees. People are scared to take a chance if they don't have medical." For now, though, his advisers have told him to wait. "They say, 'Nothing has changed, don't do anything. Let others feel the pain while it works itself out.' "
But he continued: "We are big believers in spending money to make money. So when we get to the point where it will hold back our success, we'll have to do it. At the end of the day, we're going to have to shimmy out on that branch, but in the meantime we're going to try to make do with less than 49 employees."
Mr. Hawkins also said that this conversation had prompted his partner to take a fresh look at offering health insurance now. "We're re-examining as a result of your email, so that's a good thing if we CAN actually afford," he wrote in an email.
All of which raises a question: If Mr. Hawkins knew that his company might be ready to expand beyond 50 employees as soon as next year and if he was willing to reconsider offering health insurance before then, what moved him to leave such a definitive comment on our post? He said it was an expression of his frustration with just how complex the Affordable Care Act is and how the resulting confusion has paralyzed his company.
"It's typical government," said Mr. Hawkins, who claims libertarian leanings but not any particular animosity toward President Obama. "They're making it more convoluted by the day. It's hard to understand.
"My time is at a premium. I get mad when I am spending effort and brain cells trying to understand something and I'm going backwards. My progress at best has been like a treadmill. I'm making good time and not getting anywhere. I'm educated, and I can figure most things out. I can't figure this out.
"And it makes me feel dumb. And it keeps me from doing what I want to do, which is hire more people and offer them medical - to take care of them, so they're not worried about that."
Mr. Hawkins promised to keep us informed. When he does, we'll update his story. And if you have questions about how the Affordable Care Act will affect how your business offers group health insurance, please send an email to robb.mandelbaum@nytimes.com.
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January 13, 2017 Friday 00:00 EST
Donald Trump's Medical Delusions;
Op-Ed Columnist
BYLINE: PAUL KRUGMAN
SECTION: OPINION
LENGTH: 832 words
HIGHLIGHT: Magical thinking won't work on health care.
Thanks, Comey.
The Justice Department's inspector general is now investigating the way the F.B.I. director conveyed the false impression of an emerging Clinton scandal just days before the election, even as he said nothing about ongoing investigations into Russian intervention and possible collusion with the Trump campaign. That action very probably installed Donald Trump in the White House. And it's already obvious that the incoming commander in chief will be a walking, tweeting ethical disaster.
On the other hand, he's also dangerously delusional about policy.
Some Republicans appear to be realizing that their long con on Obamacare has reached its limit. Chanting "repeal and replace" may have worked as a political strategy, but coming up with a conservative replacement for the Affordable Care Act - one that doesn't take away coverage from tens of millions of Americans - isn't easy. In fact, it's impossible.
But it seems that nobody told Mr. Trump. In Wednesday's news conference, he asserted that he would submit a replacement plan, "probably the same day" as Obamacare's repeal - "could be the same hour" - that will be "far less expensive and far better"; also, with much lower deductibles.
This is crazy, on multiple levels.
The truth is that even if Republicans were settled on the broad outlines of a health care plan - the way Democrats were when President Obama took office - turning such an outline into real legislation is a time-consuming process.
In any case, however, the G.O.P. has spent seven years denouncing the Affordable Care Act without ever producing even the ghost of an alternative. That's not going to change in the next few weeks, or ever. For the anti-Obamacare campaign has always been based on lies that can't survive actual repeal.
A prime example is the pretense that health reform hasn't helped anyone. "Things are only getting worse under Obamacare," declared Paul Ryan, the speaker of the House, last week. Yet the reality is that there has been a dramatic reduction in the number of Americans without insurance since reform went into effect - and an overwhelming majority of those covered by the new health exchanges are satisfied with their coverage.
How have Republicans nonetheless been able to get away with this lie? Part of the answer is that many of the newly insured don't know that they're being covered via Obamacare, or at any rate don't realize that they will lose coverage if it's repealed.
But that will change if repeal proceeds. For example, the percentage of nonelderly white adults without insurance fell by almost half from 2010 to 2016, from 16.4 to 8.7, a gain surely concentrated in the Trump-supporting white working class. Repeal would send that number right back up, and there would be no hiding the damage.
Meanwhile, Republicans have made hay over this year's increase in insurance premiums. But this looks very much like a one-time adjustment; and the broader picture is that health costs have actually gone up much more slowly since Obamacare was enacted than they did before, in part due to the law's cost-control features, which have worked far better than most expected.
And if the Affordable Care Act is killed, myths about its costs will be replaced by the reality of soaring bills for millions of Americans who don't realize how much the act has helped them.
But won't Trumpcare solve all these problems, by offering something much better and cheaper? Not a chance.
Republicans don't have a health care plan, but they do have a philosophy - and it's all about less. Less regulation, so that insurers can turn you down if you have a pre-existing condition. Less government support, so if you can't afford coverage, too bad. And less coverage in general: Republican ideas about cost control are all about "skin in the game," requiring people to pay more out of pocket (which somehow doesn't stop them from complaining about high deductibles).
Implementing this philosophy would deliver a big windfall to the wealthy, who would get a huge tax cut from Obamacare repeal, and it would mean lower premiums for a relatively small number of currently healthy individuals - especially if they're rich enough that they don't need to worry about high deductibles.
But the idea that it would lead to big cost savings over all is pure fantasy, and it would have a devastating effect on the millions who have gained coverage during the Obama years.
As I said, it looks as if some Republicans realize this. They may go ahead with repeal-but-don't-replace anyway, but they'll probably do it because they believe they can find some way to blame Democrats for the ensuing disaster.
Mr. Trump, on the other hand, gives every impression of having no idea whatsoever what the issues are. But then, is there any area of policy where he does?
Read my blog, The Conscience of a Liberal, and follow me on Twitter, @PaulKrugman.
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(First Draft)
September 22, 2015 Tuesday
Hillary Clinton to Present Health Care Plan
BYLINE: AMY CHOZICK
SECTION: US; politics
LENGTH: 505 words
HIGHLIGHT: Hillary Rodham Clinton will present a proposal to decrease the cost of prescription medication, as part of a series of campaign events devoted to health care policy and how she would build on the Affordable Care Act.
Hillary Rodham Clinton will present on Tuesday a multipart plan to decrease the cost of prescription medication, as part of a series of campaign events this week devoted to health care policy and how she plans to "build on the progress" made under the Affordable Care Act.
The prescription drug plan, which Mrs. Clinton will outline at a town hall event in Des Moines, includes regulating the percentage of revenues pharmaceutical companies must spend on research and development, instituting a cap on the cost of many out-of-pocket drugs for chronic and serious health conditions, and allocating additional funding to put more generic versions of drugs on the market.
On Wednesday, Mrs. Clinton is expected to present a plan to rein in the cost of nonpharmaceutical health care expenses.
"All of the Republican candidates for president are determined to get rid of the Affordable Care Act," Mrs. Clinton told a crowd in Baton Rouge, La., on Monday. "I'm not going to let them tear up that law, kick 16 million people off health coverage."
But Mrs. Clinton has also consistently said that the health care act, President Obama's signature policy achievement, is flawed and that if elected she would work out the kinks. "My attitude is, look, we've got some good things done, let's preserve what works and fix what doesn't," she told voters in New Hampshire last week.
On Monday, Mrs. Clinton posted a link on Twitter to an article about extreme and sudden jumps in the pricing of drugs. A 62-year-old drug used to treat a life-threatening parasitic infection, for example, went overnight from costing $750 a tablet from $13.50.
"Price gouging like this in the specialty drug market is outrageous," Mrs. Clinton wrote. "Tomorrow I'll lay out a plan to take it on."
That plan includes a monthly cap on the amount insurers could ask people to pay out of pocket for specialty drugs, and increased competition for generic versions of specialty drugs.
The plan would also allow Americans to import lower-cost drugs from abroad, within the confines of Food and Drug Administration safety regulations, and prohibit drug companies from keeping generics off the market, which would save an estimated $10 billion, according to her campaign.
As in her 2008 campaign, Mrs. Clinton proposes allowing Medicare to negotiate with drug companies to rein in drug costs. The current plan would also require drug companies to provide higher rebates in a Medicare program that provides subsidies to low-income seniors, which her aides estimate would save more than $100 billion in Medicare costs.
Health care has long been a priority issue for Mrs. Clinton, who embraced health care reform as first lady with a plan that ultimately failed in a public and crushing defeat. On Monday, Gov. Bobby Jindal of Louisiana called Mrs. Clinton "the godmother of socialized medicine," a title she seemed to embrace.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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September 21, 2015 Monday
Hillary Clinton to Present Health Care Plan
BYLINE: AMY CHOZICK
SECTION: US; politics
LENGTH: 505 words
HIGHLIGHT: Hillary Rodham Clinton will present a proposal to decrease the cost of prescription medication, as part of a series of campaign events devoted to health care policy and how she would build on the Affordable Care Act.
Hillary Rodham Clinton will present on Tuesday a multipart plan to decrease the cost of prescription medication, as part of a series of campaign events this week devoted to health care policy and how she plans to "build on the progress" made under the Affordable Care Act.
The prescription drug plan, which Mrs. Clinton will outline at a town hall event in Des Moines, includes regulating the percentage of revenues pharmaceutical companies must spend on research and development, instituting a cap on the cost of many out-of-pocket drugs for chronic and serious health conditions, and allocating additional funding to put more generic versions of drugs on the market.
On Wednesday, Mrs. Clinton is expected to present a plan to rein in the cost of nonpharmaceutical health care expenses.
"All of the Republican candidates for president are determined to get rid of the Affordable Care Act," Mrs. Clinton told a crowd in Baton Rouge, La., on Monday. "I'm not going to let them tear up that law, kick 16 million people off health coverage."
But Mrs. Clinton has also consistently said that the health care act, President Obama's signature policy achievement, is flawed and that if elected she would work out the kinks. "My attitude is, look, we've got some good things done, let's preserve what works and fix what doesn't," she told voters in New Hampshire last week.
On Monday, Mrs. Clinton posted a link on Twitter to an article about extreme and sudden jumps in the pricing of drugs. A 62-year-old drug used to treat a life-threatening parasitic infection, for example, went overnight from costing $750 a tablet from $13.50.
"Price gouging like this in the specialty drug market is outrageous," Mrs. Clinton wrote. "Tomorrow I'll lay out a plan to take it on."
That plan includes a monthly cap on the amount insurers could ask people to pay out of pocket for specialty drugs, and increased competition for generic versions of specialty drugs.
The plan would also allow Americans to import lower-cost drugs from abroad, within the confines of Food and Drug Administration safety regulations, and prohibit drug companies from keeping generics off the market, which would save an estimated $10 billion, according to her campaign.
As in her 2008 campaign, Mrs. Clinton proposes allowing Medicare to negotiate with drug companies to rein in drug costs. The current plan would also require drug companies to provide higher rebates in a Medicare program that provides subsidies to low-income seniors, which her aides estimate would save more than $100 billion in Medicare costs.
Health care has long been a priority issue for Mrs. Clinton, who embraced health care reform as first lady with a plan that ultimately failed in a public and crushing defeat. On Monday, Gov. Bobby Jindal of Louisiana called Mrs. Clinton "the godmother of socialized medicine," a title she seemed to embrace.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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January 28, 2017 Saturday
Late Edition - Final
G.O.P., in Private, Airs Its Anxiety Over Health Act
BYLINE: By ROBERT PEAR and THOMAS KAPLAN; Robert Pear reported from Washington, and Thomas Kaplan from Philadelphia.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1590 words
WASHINGTON -- Congressional Republicans, meeting behind closed doors this week in Philadelphia, expressed grave concerns about dismantling the Affordable Care Act on the urgent timetable demanded by President Trump, fretting that, among other things, they could wreck insurance markets and be saddled with a politically disastrous ''Trumpcare.''
An audio recording of a session at their annual retreat, obtained by The New York Times, shows Republicans in disarray, far from agreement on health policy, and still searching for something to replace former President Barack Obama's health care law. While their leaders called for swift action to rescue consumers from the Affordable Care Act, some backbench Republicans worried about potential pitfalls.
''We had better be sure that we are prepared to live with the market being created,'' said Representative Tom McClintock of California, because ''that's going to be called Trumpcare.''
He added, ''Republicans will own it lock, stock and barrel, and we'll be judged on that.''
When Democrats were writing the Affordable Care Act seven years ago, their primary goal was to provide health insurance to more people, an ambition that the Obama administration went to great lengths to fulfill as it enrolled millions of people in Medicaid or private health plans.
Now, as Republicans try to devise a replacement for the law, they have set a nearly impossible standard for themselves: They have promised that none of the 20 million people who gained coverage through the Affordable Care Act will lose it if the law is repealed, even as they lift its mandates and penalties, pull back the tax increases that pay for it and pledge to enact a new program that will be cheaper for taxpayers and consumers.
In their private session, the recording of which was first reported on by The Washington Post, Republicans revealed that they understood the predicament they had largely created for themselves.
''I recognize that we can't keep Obama's promises,'' Representative Tom MacArthur of New Jersey said. ''They were wrong to begin with, and the system can't be sustained.'' He worried aloud about the possibility that some people could lose insurance as the law is unwound.
''We're telling those people that we're not going to pull the rug out from under them, and if we do this too fast, we are, in fact, going to pull the rug out from under them,'' Mr. MacArthur said. After giving states the choice to expand Medicaid under the law, he said, reversing that expansion too quickly would run the risk of pulling a ''bait and switch with the states.''
The lawmakers' concerns contrasted with the confidence that Republican leaders and President Trump have expressed as they rush to replace Mr. Obama's signature domestic achievement, also known as Obamacare. Congress this month approved a budget blueprint that clears the way for quick action to repeal major provisions of the law, and Mr. Trump has said Congress should repeal and replace the law at the same time, putting pressure on lawmakers to agree on an alternative.
That budget measure created an aspirational deadline to draft repeal legislation by Jan. 27, a day that came and went.
Privately, Republicans made clear they understand the risks they are running. At their session this week, they voiced concern that their efforts to undo the law could have harmful consequences, such as inadvertently destabilizing insurance markets -- a concern shared by Democrats and insurers.
Under Senate rules, the Senate could vote to repeal major provisions of the Affordable Care Act using fast-track procedures that neutralize the threat of a Democratic filibuster. ''We can repeal parts of it,'' Mr. McClintock said, ''and the parts that remain, I'm concerned, could make the market even more dysfunctional.''
Republican leaders tried to reassure anxious backbenchers, making the same points in private as they have in public.
''We don't own Obamacare,'' said Senator John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, adding: ''We are the rescue party. We campaigned to provide relief and help repair the damage.''
Republican leaders have predicted that Democrats will come to the table to help draft a replacement once it becomes clear that the health law will be repealed. But some rank-and-file members were not so sure.
Representative John Katko of New York wondered what Republicans would do ''if we can't get anything out of the Democrats.''
Another New York Republican, Representative John J. Faso, warned colleagues they were playing with fire if they cut off funds for Planned Parenthood clinics, as Speaker Paul D. Ryan has said Republicans intend to do.
''Health insurance is going to be tough enough for us to deal with, without allowing millions of people on social media to come to Planned Parenthood's defense,'' Mr. Faso said. He wanted to know from the administration that ''we're not going to have a tweet from the president'' saying ''we should protect Planned Parenthood.''
''We're making a grave mistake including this Planned Parenthood provision in a health care bill,'' he said.
For many Republicans, coverage and cost are still the most important issues. Estimates of the number of people who will gain or lose coverage will affect the outlook for any proposal to dismantle and replace the 2010 law. If the Congressional Budget Office, the nonpartisan scorekeeper on Capitol Hill, concludes that a significant number of people could lose coverage under a Republican plan, opposition from lawmakers -- including Republicans -- could jeopardize passage.
Before Mr. Trump stepped into the debate with his call for ''insurance for everybody,'' Republicans were choosing their words with utmost caution: Their goal in replacing the health law was to guarantee ''universal access,'' they said, not necessarily universal coverage.
''We will give everyone access to affordable health care coverage,'' Mr. Ryan said in early December when asked if Republicans had a plan to cover everyone.
But that discipline has broken down as lawmakers hear from constituents terrified of losing insurance and as Mr. Trump weighs in.
''No one who has coverage because of Obamacare today will lose that coverage,'' Representative Cathy McMorris Rodgers of Washington, the chairwoman of the House Republican Conference, said on Jan. 10.
A spokeswoman for Ms. McMorris Rodgers later tried to clarify what she had said. The congresswoman ''didn't deliver her remarks exactly as prepared,'' the spokeswoman said. In the prepared remarks, Ms. McMorris Rodgers included an important qualification: ''No one who has coverage because of Obamacare today will lose that coverage the day it's repealed'' -- in the transition to a new market-oriented health care system.
But Senator John Cornyn of Texas, the No. 2 Senate Republican, has made a sweeping commitment just like the one by Ms. McMorris Rodgers. After meeting with governors on Jan. 19, Mr. Cornyn was asked about concerns that people who benefited from the expansion of Medicaid might lose that coverage with a repeal.
''We're all concerned, but it ain't going to happen,'' Mr. Cornyn said. He amplified the point, adding: ''Nobody's going to lose coverage. Obviously, people covered today will continue to be covered. And the hope is we'll expand access. Right now 30 million people are not covered under Obamacare.''
A spokesman for Mr. Cornyn said he ''meant no one will lose access to coverage.''
Chris Jacobs, a health policy analyst who used to work for Republicans in Congress, said Republicans and Mr. Trump were at risk of overpromising, just as Mr. Obama did.
''Conservatives should not remain fixated on the number of people with health insurance when designing an Obamacare alternative,'' Mr. Jacobs said. ''We will never win the battle with liberals if you measure success in terms of how many people have health insurance cards. We don't want to spend as much as liberals, and we don't believe in coercing people to buy insurance.''
Democrats remember how Republicans hounded Mr. Obama for breaking his promise that ''if you like your health care plan, you can keep your health care plan.'' Democrats say they will hold congressional Republicans and the Trump administration accountable in the same way.
Increasing the number of people with insurance was a lodestar for the Obama administration. It spent tens of millions of dollars advertising the benefits of the law. It extended deadlines to give people more time to sign up. It allowed many people to sign up outside the regular annual enrollment period and played down the significance of big premium increases, saying consumers could get subsidies to defray the costs.
Republicans say they can get the same results for less money and without a statutory mandate that most Americans have insurance. But without that requirement, budget analysts say, it will be difficult for Republicans to achieve coverage gains as large as those achieved under the Affordable Care Act.
''It's easier for the Congressional Budget Office to estimate significant coverage effects if there is a federal requirement'' for people to have insurance, said Douglas W. Elmendorf, who was the budget office director from 2009 to 2015. ''It would be very hard to maintain the levels of insurance coverage we have now without the penalties and subsidies.''
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URL: http://www.nytimes.com/2017/01/27/us/politics/affordable-care-act-republican-retreat.html
LOAD-DATE: January 28, 2017
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GRAPHIC: PHOTO: House Speaker Paul D. Ryan, Republican of Wisconsin, center, has expressed confidence in public over his party's rush to replace the Affordable Care Act. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A11)
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February 12, 2014 Wednesday
Demoralization Is Not a Policy Achievement
SECTION: BUSINESS; economy
LENGTH: 922 words
HIGHLIGHT: The White House and its allies are trying to put a very positive spin on the destructive aspects of some of its policies, including the Affordable Care Act, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Economists working for Democratic administrations in the past used to shine a light on high marginal tax rates and the extensive economic damage the rates cause. Last week White House economists and their allies remarkably reclassified such rates as a policy achievement.
Ever since the 2008 crisis, the federal government has been creating policies that eliminate the reward to working for millions of households by giving so many benefits to people who work part time or spent a greater fraction of the year out of work that family decisions to work more result in less money for them to spend.
In the George W. Bush administration, for example, the Federal Deposit Insurance Corporation offered a mortgage modification program that created terrible work incentives. Then came the American Recovery and Reinvestment Act, under which about four million people could earn more by remaining unemployed longer, because going back to work would erase federal health assistance and multiple sources of cash benefits.
The latest is the Affordable Care Act, which has created a system of health assistance that withholds its benefits on the basis of income and, in most cases, on the basis of full-time employment. A part-time worker may actually have less to spend if he takes on a full-time position. This kind of situation will occur at least a million times under the new law.
(I blogged about this earlier and now have a two-minute video clip that walks more thoroughly through the arithmetic. These effects, by the way, did not begin until this year and will not have their full effect until the new health exchanges are working as intended and citizens become aware of the new incentives they face, so there is no point looking in the 2013 data to measure them.)
This does not even begin to count how many millions of people will have their reward to work fully eliminated by "cliffs" in the premium assistance, cost-sharing and tax-credit reconciliation parts of the act.
It used to be that economists agreed that such stark disincentives - known as 100 percent tax rates - were a serious problem that needed immediate attention. As James Tobin, a John F. Kennedy adviser, Nobel laureate and leading Keynesian economist of his day, said in a 1965 article, a 100 percent tax rate causes "needless waste and demoralization," adding:
This application of the means test is bad economics as well as bad sociology. It is almost as if our present programs of public assistance had been consciously contrived to perpetuate the conditions they are supposed to alleviate.
Professor Tobin called the 100 percent tax situation demoralizing because the affected people find that all the benefits of their hard work and success go to the government in the form of more tax receipts and fewer benefit payments. The unintended result would be less work and more families earning less than the poverty line, which is why Professor Tobin described such policies as perpetuating poverty.
The Congressional Budget Office was one of the first to point out some of the high marginal tax rates in the Affordable Care Act, although at the time it was not aware of the 100 percent tax on full-time work. But the C.B.O.'s work on marginal tax rates had been kept separate from its work on the economic impact of the Affordable Care Act until now.
Last week's big economic news was that the C.B.O. had begun using its longstanding work on marginal tax rates to inform its projections of the health law's economic impact, and had recently concluded that the law would make the labor market significantly smaller. The new report also showed that C.B.O. was aware of instances of 100 percent marginal tax rates, including the one I cited above (see the sentence in its report that spans Pages 119 and 120, including the footnote), although I don't know to what degree, if any, the prohibitive rates informed C.B.O.'s impact estimate.
No modern-day James Tobin stepped forward to proclaim that it was a serious policy mistake to wipe away the reward to work for millions of people. Instead, the White House spun the high marginal tax rates as a policy achievement, saying "individuals will be empowered to make choices about their own lives and livelihoods" and adding that people "would have the opportunity to pursue their dreams." (The White House also quickly pivots away from high marginal tax rates to so-called job lock, which is a completely different issue than 100 percent marginal tax rate and far less prevalent.)
White House allies are in no hurry to emulate Professor Tobin, either. Instead they cheer about the voluntary aspects of the economic destruction done by high marginal tax rates. As Jonathan Gruber put it, "Voluntary reductions are not a cost of the health care reform law, they are a benefit." Paul Krugman goes even further and calls it "misrepresentations" to interpret the marginal tax rate provisions of the Affordable Care Act as destructive.
Prohibitive marginal tax rates are not a policy achievement. Sadly, the economic problems the rates create cannot be fixed as long as those in power deny that a problem even exists.
A Report's Real Message: It Wasn't About Health Care
Shorter Workweeks Are Likely in New Year
Changing Assistance for the Unemployed
The Unemployment Rate at Full Employment: How Low Can You Go?
Little Sign of Jobs Impact From Health Care Law
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The New York Times
January 27, 2015 Tuesday
Late Edition - Final
Budget Office Slashes Estimated Cost of Health Coverage
BYLINE: By ROBERT PEAR
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WASHINGTON -- The Congressional Budget Office on Monday significantly lowered its estimate of the cost of providing health insurance coverage to millions of Americans under the Affordable Care Act.
Douglas W. Elmendorf, the director of the budget office, said the changes resulted from many factors, including a general ''slowdown in the growth of health care costs'' and lower projections of insurance premiums that are subsidized by the federal government.
In March 2010, when President Obama signed the health care law, the Congressional Budget Office estimated that the expansion of coverage would cost the federal government $710 billion in the fiscal years 2015 through 2019, Mr. Elmendorf said.
''The newest projections indicate that those provisions will cost $571 billion over that same period, a reduction of 20 percent,'' he said. The Affordable Care Act not only subsidized the purchase of private insurance, but also authorized a major expansion of Medicaid, the federal-state program for low-income people.
The Supreme Court ruled in 2012 that the expansion of Medicaid was optional for states, not required, as Democrats in Congress had intended. Nearly two dozen states have yet to expand eligibility. And in states that did expand Medicaid, projections of federal Medicaid spending per beneficiary are lower than expected, the budget office said.
The new estimates may help Democrats trying to preserve the Affordable Care Act in the face of fierce criticism from Republicans, who control Congress and maintain that the law will contribute to explosive health spending.
On the other hand, several factors cited by the budget office may not be politically popular. For example, it said that a new excise tax on high-premium insurance, which takes effect in 2018, would generate substantial new revenue for the government -- $149 billion in the first eight years. And it predicted that the number of people with employer-sponsored insurance would be lower than it would otherwise have been in the absence of the law.
The Obama administration has been reluctant to provide detailed estimates of the cost of the Affordable Care Act, often relying on estimates by the Congressional Budget Office. Mr. Elmendorf estimated that the federal subsidies for private insurance purchased through public exchanges would total nearly $1.1 trillion from 2016 to 2025, while the federal government would spend $920 billion on Medicaid and the Children's Health Insurance Program in those years as a result of the law.
The subsidies in that 10-year period include $909 billion in tax credits and $147 billion to reduce deductibles and other out-of-pocket costs for low-income people.
As a result of the health care law, Mr. Elmendorf said, Medicaid enrollment increased last year by eight million people -- six million who became newly eligible and two million who were previously eligible but not enrolled.
For 2015 and beyond, he said, ''roughly 70 percent of the people who will receive Medicaid coverage because of the Affordable Care Act will be newly eligible for the program.'' The federal government will pay 90 percent to 100 percent of Medicaid costs for the newly eligible group, compared with an average of 57 percent for other beneficiaries.
The Obama administration said that 7.3 million people had bought private insurance through the exchanges and paid their share of premiums last year. The budget office predicts that this number will climb to 12 million in 2015 and will reach 25 million in 2017. About three-fourths of those subscribers are expected to receive federal subsidies, the budget office said.
That estimate underlines the importance of a case in front of the Supreme Court this term in which critics of the law are challenging subsidies paid to low- and moderate-income people in states that refused to establish their own exchanges.
The subsidies will cost the government less than originally expected, but are still substantial, the budget office said. ''Subsidies in the exchanges are projected to average about $5,000 per subsidized enrollee from 2016 through 2018 and to reach almost $8,000 in 2025,'' Mr. Elmendorf said.
All told, the budget office said, the coverage provisions of the health care law will have a gross cost of nearly $2 trillion over the next 10 years, partly offset by $643 billion in new revenues and penalty payments. The law will reduce the number of uninsured by 27 million people, it said, but 31 million people will still be uninsured in 2025, the end of the projection period.
Of those expected to lack health insurance in 2025, the budget office predicted 30 percent would be unauthorized immigrants, 10 percent would be ineligible for Medicaid because they live in states that did not expand coverage, and the rest would have access to public or private insurance but opt not to enroll.
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November 25, 2011 Friday
The Supreme Court and Health Care
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 966 words
HIGHLIGHT: President Obama has not made the strongest arguments possible for his health-insurance law, an economist writes.
For decades Americans have been served, in the print media and on television, with sorry vignettes of fellow Americans who have seen their health-insurance premiums increased or lost their insurance coverage altogether because illness struck or were denied coverage because of pre-existing medical conditions.
As a result, these Americans may find themselves hounded by bill collectors on behalf of the doctors and hospitals who treated them. One major illness can wipe out their lifetime savings, house included.
Sometime in 2012, probably just before its current term ends at the end of June, the Supreme Court will decide whether Americans will just have to live with that problem, or, alternatively, like citizens in virtually any other industrialized country, they will have the right to have this problem lifted off their shoulders.
On Nov. 14, the Supreme Court, in legal jargon, granted a writ of certiorari in response to a petition to review a decision by the United States Court of Appeals for the 11th Circuit that had struck down a mandate in the Affordable Care Act. That mandate requires that every person have at least a minimally adequate health insurance policy, with the aid of federal subsidies where needed.
Naturally, the justices will be making major health policy.
Over the last half-century, Congress has repeatedly tried to fix the problem described in the opening paragraph. The Affordable Care Act passed by Congress in March of 2010 is by no means the only attempt to fix this problem.
One earlier attempt, for example, was President Clinton's ill-fated Clinton Health Security Act of 1993. Another was a Republican counterproposal, introduced in 1993 and also ill-fated.
More recently, in an interesting counterproposal to the Affordable Care Act, Senator Tom Coburn, Republican of Oklahoma, offered the Patients' Choice Act of May 2009. It never reached the floor of the Senate.
Finally, we have the Affordable Care Act of March 2010, which did become law, although the fate of one of its centerpieces - the mandate to have insurance -- now is in the minds and hands of the Supreme Court justices.
All of these proposals have in common that they sought to solve the problem with two major mandates on private health insurers: "community rated" health-insurance premiums and "guaranteed issue."
Community-rated premiums are divorced from the individual applicant's age, gender and health status and reflect only the average annual per-capita actuarial cost of entire communities. Guaranteed issue is a mandate upon health insurers to offer health insurance to anyone willing to pay the quoted premium.
As I have explained in detail in several earlier posts, forcing upon private insurers a mandate of community rating and guaranteed issue will not work, unless accompanied by a mandate upon all citizens to have at least a minimally adequate health insurance policy with specified benefit coverage.
To see why it is so, keep in mind what a combination of community rating, guaranteed issue and a mandate to be insured seeks to achieve. The aim is to create a risk pool in which younger and healthier enrollees subsidize through their community-rated premiums the health care of older or sicker individuals. It redistributes income, at any point in time, through the insurance premium.
Naturally, under a one-sided mandate of community rating and guaranteed issue, without a mandate to be insured, healthier and younger individuals will see advantage in gambling, remaining uninsured until illness strikes, at which time one can them throw oneself on the mercy of community rating and guaranteed issue.
Remarkably, younger and healthier individuals in other industrialized countries have long accepted the mandate to be insured in return for community-rated premiums and guaranteed issue. Perhaps they think of the arrangement as a distant cousin of a call option on a common stock.
In this case, the premium that younger and healthier individuals pay for the call option is the difference between the community-rated premiums and what a premium based on their health status (an "actuarially fair" premium) would be. The benefit of this call option is that later in life, or when illness strikes, the individual can obtain health insurance coverage at a premium much below the actuarially fair premium.
To my knowledge, President Obama has never explained the mandate in the Affordable Care Act to young people in this way. Perhaps he should.
New York and New Jersey have sought to override basic actuarial principles by mandating community rating and guaranteed issue on insurers without a mandate on individuals to be insured. It is about as sensible as the idea of manufacturing two-legged stools.
Alan Monheit and his colleagues have described with great clarity how that infelicitous legislation in New Jersey has resulted in shrunken risk pools of mainly sicker individuals and how as a result community-rated premiums for individual coverage has increased.
To get a feel for the impact of the one-sided mandate in New York, readers might look at the staggeringly high premiums quoted by United Healthcare Oxford for its "NY Personal Point of Service Liberty Network" insurance policy. For individual policies, the quoted premium is $1,855.97 a month; for families, $5,707.11. Premiums for the carrier's "NY Personal HMO Plan-Liberty Network" are lower, but still high at $1,259.77 for the individual and $4,749.46 for families.
One must wonder whether the Supreme Court justices' legal fortitude is such as to abstract from these facts the real world.
The Case for Higher Taxes
Equalizing Payments for Medical Care
The Money Flow From Households to Health Care Providers
The Human-Capital Approach to Occupational Choice
Vermont's Move Toward Single-Payer Health Insurance
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November 12, 2013 Tuesday
Jarrett Promises Outreach to Business Leaders
BYLINE: RACHEL ABRAMS
SECTION: BUSINESS
LENGTH: 298 words
HIGHLIGHT: Valerie Jarrett, a senior adviser to President Obama, pointed out that “millions of Americans” have already benefited from the health care law.
A number of speakers at Tuesday's DealBook conference addressed the Affordable Care Act, but the law's fumbled rollout has arguably been the biggest headache for Valerie Jarrett, a senior adviser to President Obama.
"Obviously there's no one more frustrated than the president that the website hasn't lived up to our expectations," Ms. Jarrett told the audience during a conversation with David Leonhardt, the Washington bureau chief for The New York Times. She emphasized that the president has taken "immediate action" to fix the problems.
The president has lit a fire under his staff to fix issues with HealthCare.gov, the online marketplace where consumers can purchase insurance under the new regulations. While Ms. Jarrett acknowledged the problems, she also said that "millions of Americans" have already benefited from the law.
"There isn't an American who isn't going to be touched in a positive way by the Affordable Care Act," Ms. Jarrett said. "Change is difficult. Even change for the better is difficult."
Ms. Jarrett said she herself had benefited by being able to keep her daughter on her health plan until she turned 26.
Earlier in the day, Laurence D. Fink, the chairman and chief executive of BlackRock, said that the Obama administration had reached out more to business than "any White House in modern time."
Ms. Jarrett did not appear to disagree. She pledged continuing transparency and communication with business leaders, even though issues like corporate tax reform could cause friction.
Ms. Jarrett said the government has taken "enormous strides" in reaching out to business over the past five years, and "we still have work to do. But we're going in the right direction."
Fink Worries About Implications of Health Care Law
Investors in Health Care Seem to Bet on Incumbent
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January 5, 2017 Thursday 00:00 EST
Democrats Appeal for Compromise: Alter, but Don't Gut, the Health Law
BYLINE: THOMAS KAPLAN and ROBERT PEAR
SECTION: US; politics
LENGTH: 1183 words
HIGHLIGHT: A group of Democrats sent a letter to Republicans, requesting that they slow down the repeal efforts and instead find bipartisan changes to the existing law.
WASHINGTON - With Republican leaders pressing to dismantle the Affordable Care Act, possibly within weeks, moderate Senate Democrats reached out on Thursday to Republicans, appealing for them to slow down the repeal efforts and let lawmakers try to find acceptable, bipartisan changes to make the existing law work better.
Democrats also had new reason to hope for possible Republican defections after Speaker Paul D. Ryan of Wisconsin said that the repeal measure would cut off federal funds for Planned Parenthood. But for now, Republican leaders are holding firm. Senator Mitch McConnell of Kentucky, the majority leader, denounced the law, President Obama's signature domestic achievement, as "a lesson to future generations about how not to legislate."
Well before Republicans seized control of Washington, moderate Democrats and Republicans in the Senate had begun exploring ways to change the law, tempering its impacts on small business, seeking lower-cost insurance options and changing how quickly subsidies to help purchase insurance policies would phase out with rising incomes.
But those efforts were stymied by Republican leaders who had no interest in improving the health law and by Democratic leaders who saw reopening the law as a political Pandora's box. Now, Democrats have every interest in opening that box as repeal efforts barrel forward, and they would need to peel off only a few Senate Republicans to slow the fast-track repeal movement.
A possible pressure point is the effort to end funding for Planned Parenthood in the same measure that guts the health law. Already, that has raised questions about the support of two Republicans, Senators Susan Collins of Maine and Lisa Murkowski of Alaska.
"We ought to be talking about reform," Senator Tim Kaine of Virginia, who led the group of Democrats who reached out to Republican leaders, said on Thursday. "And if Republicans want to call it 'replace' and we want to call it 'reform' or 'improvement' - I don't care what we call it."
"There's so much we can improve, but by pushing an immediate repeal through a partisan budget process, we won't have the opportunity to work together to build on that common ground," Mr. Kaine, who was the Democratic vice-presidential nominee, added.
Senate Republicans plan to muscle through a budget blueprint next week that clears the way for the repeal of major parts of the Affordable Care Act without the prospect of a Democratic filibuster. The House plans to take up the blueprint as soon as the Senate approves it.
House and Senate committees would then have until Jan. 27 to produce legislation that eviscerates a law that has extended health coverage to 20 million Americans and protected millions more from discriminatory insurance practices. But it has also been plagued by rising premiums and limited insurance company participation.
If Republicans succeed in gutting the law, they would need Democratic help to find a replacement, because the Republicans' narrow Senate majority would surely face a filibuster of a partisan health bill. "We want their ideas," Mr. McConnell said. "We want their input."
But the effort to quickly undo a law that cost the Democrats so much effort and political capital could poison any chance of cooperation later this year.
Senator Chuck Schumer of New York, the Democratic leader, said on Thursday that Mr. McConnell and his colleagues have two options. One, he said, is for Republicans to devise a plan on their own to replace the health care law.
"Or don't repeal and come talk to us about how to make some improvements," Mr. Schumer said. "We're willing to do that."
For now, though, Republican leaders are in no mood to compromise. Senator John Cornyn of Texas, the No. 2 Senate Republican, dismissed the appeal from the group of Democrats as an "act of desperation."
"The fact is the wheels have been coming off of Obamacare for a long time now," he said, adding that he understood that the Democratic senators, "as a political matter," feel that they need to defend the health care law.
The request for Republicans to slow down and work with them on changing the health care law came in a letter from 13 senators - 12 Democrats and an independent, Angus King of Maine.
Moderate Democrats for years have been suggesting changes in the Affordable Care Act, based in part on complaints they were hearing from constituents.
In 2014, for example, Senators Heidi Heitkamp of North Dakota and Mark Warner of Virginia, both Democrats, proposed a lower-cost, high-deductible option - a "copper plan," to go along with bronze, silver, gold and platinum plans already available under the law. Both signed Mr. Kaine's letter.
As a possible model for bipartisan cooperation, senators pointed to a bill signed by Mr. Obama in October 2015 that protected small and midsize businesses from increases in health insurance premiums. Senators Jeanne Shaheen, Democrat of New Hampshire, and Tim Scott, Republican of South Carolina, led efforts to pass that bill. Ms. Shaheen also signed Mr. Kaine's letter.
White House officials said Mr. Obama did not particularly like that legislation but signed it after it won broad bipartisan support.
As Republicans moved ahead with their plans for repeal, the Planned Parenthood issue began picking up steam after Mr. Ryan said on Thursday that the health law repeal measure would cut off funds for the organization.
Such a provision could trouble moderate Senate Republicans whose votes are critical to passing repeal legislation.
"Yes, I'd have concerns," Ms. Murkowski said. "I've long been a supporter of Planned Parenthood." But Ms. Murkowski said she did not know, without seeing a bill, if cutting the funding would be enough to cause her to vote against the health care repeal.
In 2015, Ms. Collins voted against a repeal bill because it would have cut off funds for Planned Parenthood. She expressed hope on Thursday that such a provision would not be in the repeal legislation this year.
In another possible trouble spot, members of the hard-right House Freedom Caucus met on Thursday with Senator Rand Paul, Republican of Kentucky, about the budget blueprint, weighing the possibility of opposing the measure because of its increases in federal spending and debt.
The group of conservatives has a history of opposing spending measures, often against the wishes of their party's leaders. Mr. Paul has said he will not support the budget blueprint because it would allow the government to add trillions of dollars to the federal debt in the coming decade.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
Emmarie Huetteman and Jennifer Steinhauer contributed reporting.
PHOTO: Senator Tim Kaine of Virginia led the group of Democrats asking Republicans for bipartisan fixes to the Affordable Care Act. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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Job No. 1 for a New Congress? Undoing Obama's Health Law
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March 27, 2017 Monday
Late Edition - Final
Small Firms Favor Repeal but Above All Want Relief
BYLINE: By STACY COWLEY
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LaRonda Hunter, a business owner in Fort Worth, Tex., views the Affordable Care Act as a literal job killer. Fearful of triggering the law's employer mandate, which requires businesses with 50 or more workers to offer health insurance or pay penalties, Ms. Hunter has held off on expanding her small chain of hair salons.
She voted for President Trump with the hope that he would quickly make good on his promise to strike down the health care law. On Friday, she watched in despair as the Republicans' replacement plan unraveled -- leaving the law, commonly known as Obamacare, in place ''for the foreseeable future,'' according to Paul D. Ryan, the House speaker.
''I'm disappointed,'' Ms. Hunter, 57, said. ''I'm mostly mad at my party for being so disorganized. I'm hoping Trump has learned something about how the government works.''
In Brooklyn, however, another business owner, Leisah Swenson, was ecstatic about the news that Obamacare would be sticking around. Ms. Swenson, 48, and her wife, Monica Byrne, run a restaurant and a catering company. Before the health care law took effect, they struggled to find affordable insurance, and often went without. Now, they have a policy they bought through New York's state exchange, which recently paid for a critical -- and expensive -- operation for Ms. Byrne.
''We thought, 'Thank God,''' Ms. Swenson said of the Affordable Care Act's continuation. ''We're not young. The car is starting to break down a bit. If we lost this policy, we might not be able to get another.''
As a bloc, small-business owners have been among the health care law's most vocal opponents. The most powerful trade group for small businesses, the National Federation of Independent Business, is a fierce critic of the law and challenged its constitutionality before the Supreme Court. Some 60 percent of small-business owners want the law repealed, according to two recent surveys by Manta and BizBuySell, which regularly poll owners about their political and economic views.
But every business is uniquely affected by the complex law, and simply demolishing it without putting new guardrails in place is not, for most, the ideal outcome. Small-business owners overwhelmingly say they want Republican and Democratic leaders to quit their partisan bickering, acknowledge that the country's health care economics are fundamentally broken, and work together on fixing the problem.
''The cost of health care had a significant impact on our profitability last year,'' said Tom McManus, 46, the chief executive of KegWorks, a bar supplies retailer in Buffalo. ''Obamacare made it worse, but I didn't see anything in the new bill that would have made it any better. They need to focus on the real health care problem: cost.''
For Thomas E. Secor, who runs the small manufacturing business Durable Corporation in Norwalk, Ohio, every annual renewal of his company's health insurance plan since the Affordable Care Act took effect has felt like spinning a roulette wheel.
Durable Corporation's plan, which Mr. Secor said had worked well for the company's 37 employees, omits some benefits that are required to meet the health law's minimum coverage standards. So far, the plan has been grandfathered in, allowing Durable to keep it -- but if that protection ends, Mr. Secor does not know if his company can afford to continue offering insurance, he said.
''Rural areas like ours are seeing insurance companies just flee,'' Mr. Secor, 59, said. ''Until somebody comes up with something that addresses cost, you're going to see a continual erosion of coverage. I don't care which party it is. Let's all get together and work on a better product because what we have now isn't working.''
Bipartisan cooperation on anything has become vanishingly rare in Washington, but one recent effort offered a glimmer of hope: In December, the parties aligned to overwhelmingly support the 21st Century Cures Act. The law increased funding for disease research and included an array of other health care adjustments and changes.
One of them was a fix long sought by small-business owners to an obscure -- but, for some, devastating -- Affordable Care Act clause that prohibited companies from using pretax money to reimburse employees for insurance that they bought on their own. The Cures Act revived that arrangement, giving it a legal green light for companies with fewer than 50 employees.
The change came as a huge relief for Warren Hudak, 53, who immediately took advantage of it to provide the eight full-time employees at his accounting firm in Lemoyne, Pa., with a monthly allowance toward their health care costs. He would like to see a similar across-party-lines effort to curb health care costs.
''I can't believe anybody today would look at the Affordable Care Act and say, 'It's working fine,''' Mr. Hudak said.
He now pays $2,400 a month -- enough, he said with frustration, to hire another worker for his business -- for a family insurance policy with a glaring omission: It does not cover the $6,000-a-month prescription drugs his wife needs to combat her multiple sclerosis. Mr. Hudak said he had to contact the drug manufacturer himself and negotiate a discounted rate that his family could afford to pay.
''We have an insurance policy that would cover maternity and substance abuse treatment for my 11-year-old daughter but doesn't cover my wife's M.S. drugs,'' Mr. Hudak said. ''That's insane.''
Tav Gauss, 61, the founder of a staffing agency in Wilson, N.C., hopes that having Republicans in control of the federal government's executive and legislative branches will at least reduce the regulatory complexity of complying with health care mandates. He estimated that his company, which has 20 internal employees and 1,500 field workers, had spent around $80,000 on the paperwork and compliance systems that the Affordable Care Act requires.
''The rising costs have taken a toll on all of my investments in people and equipment,'' Mr. Gauss said.
Mr. Ryan and Mr. Trump have suggested that they are done with health care for the time being -- no new bill or repeal vote is forthcoming, Mr. Ryan said -- but Ms. Hunter, the Texas salon owner, thinks they will be forced back into the fray.
''I'm going to urge all of my senators and representatives to continue to work on this,'' she said. ''Waiting for it all to explode is a terrible solution.''
Mr. Secor, the Ohio manufacturer, also thinks the status quo is not sustainable. A growing number of his employees have dropped their coverage because they cannot afford the premiums and high deductibles, he said.
''People can't afford the health care they need, and that's becoming a crisis,'' he said. ''We need both parties to sit down at the table together and work it out.''
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June 22, 2016 Wednesday
Late Edition - Final
House Republicans Unveil Long-Awaited Replacement for a Repealed Health Law
BYLINE: By ROBERT PEAR
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WASHINGTON -- After six years of vague talk about a conservative alternative to the Affordable Care Act, House Republicans on Tuesday finally laid out the replacement for a repealed health law -- a package of proposals that they said would slow the growth of health spending and relax federal rules for health insurance.
Opponents began the ''repeal and replace'' mantra almost as soon as the Affordable Care Act was signed in 2010, and while they have voted dozens of times to repeal the health law, the replacement has been elusive.
In finally presenting one, Speaker Paul D. Ryan of Wisconsin and his Republican team did not provide a cost estimate or legislative language. But they did issue a 20,000-word plan that provides the most extensive description of their health care alternative to date.
Many of the ideas -- for ''health savings accounts,'' ''high-risk pools'' and sales of insurance across state lines -- are familiar. Democrats in and out of Congress have for weeks been rehearsing their lines of attack.
Others are sure to be contentious. House Republicans would gradually increase the eligibility age for Medicare, which is now 65. Starting in 2020, the Medicare age would rise along with the eligibility age for full Social Security benefits, eventually reaching 67.
Following Mr. Ryan's budget plans of recent years, the health proposal would transform Medicare into ''a fully competitive market-based model known as premium support.'' The traditional fee-for-service Medicare program would compete directly with private plans offered by companies like UnitedHealth, Aetna and Humana.
In their blueprint, to be formally unveiled on Wednesday, House Republicans say they would eliminate the requirement that most Americans carry health insurance. They would offer a flat tax credit to each person or family in the individual insurance market, regardless of income or the premium for a particular insurance policy.
House Republicans also said they would roll back the Affordable Care Act's expansion of Medicaid and give each state a fixed amount of money for each beneficiary or a lump sum of federal money for all of a state's Medicaid program.
In addition, House Republicans would allow states to establish work requirements for able-bodied adults on Medicaid, requirements that the Obama administration has refused to permit. Under the House Republican plan, states could also ''charge reasonable enforceable premiums or offer a limited benefit package'' and use ''waiting lists and enrollment caps'' for certain groups of Medicaid beneficiaries.
Using these options and others proposed by House Republicans, states could profoundly reshape the Medicaid program, which provides health insurance to more than 70 million people at a federal cost of more than $350 billion a year.
''Reforming Medicaid's financing with a per-capita allotment certainly will reduce federal spending, but just as importantly'' will give states more control over the program and more incentives to manage care and costs, the blueprint says.
The health care package is one of a half-dozen planks in the platform that Mr. Ryan describes as ''a better way.'' It is more substantive than anything offered to date by Donald J. Trump, the presumptive Republican presidential nominee, and provides a possible framework for Republican action in 2017.
Democrats say the package would reverse progress made in reducing the number of uninsured.
One of the most important provisions of the 2010 health care law stipulates that insurers cannot deny coverage or charge high premiums because of a person's medical condition or history. The House Republican blueprint would replace this guarantee with more complicated, less stringent standards.
No American could be denied coverage because of a pre-existing condition, the House Republican plan says. But the protection against higher premiums would apply only to people who maintain ''continuous coverage.'' If a consumer allows a significant break in coverage, insurers could charge more than ''standard rates'' and take a person's health status into account in setting premiums.
The House Republican plan would also change the tax treatment of some employer-provided health insurance, in a way that some employers are finding objectionable.
Under current law, employees do not have to pay federal income tax on contributions that employers make to their health insurance. House Republicans said this open-ended subsidy had encouraged people to select more expensive coverage, driving up premiums.
''To help lower the cost of coverage,'' House Republicans said, they would cap the value of tax-free benefits, but the cap would be so high that it would affect ''only the most generous plans.''
The Affordable Care Act tries to discourage inefficient insurance plans as well, through a ''Cadillac tax'' on high-cost employer-sponsored coverage, a tax that was recently delayed until 2020.
Republicans say their approach is better, but employers were quick to denounce the proposal.
''This would be a new tax on benefits, on working families, and could eventually threaten the employer-sponsored health insurance that so many Americans enjoy,'' said James P. Gelfand, senior vice president of the Erisa Industry Committee, a trade association for large employers.
House Republicans would relax age-rating restrictions in the Affordable Care Act. Under the law, insurers generally cannot charge older Americans more than three times what they charge younger people, other factors being equal. Republicans said this was ''an unrealistic regulation'' that led to ''higher premiums for millions of Americans, especially younger and healthier patients.''
House Republicans would allow a ratio of five to one, with states permitted to set more or less restrictive rules.
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Uncomfortable Question for Ted Cruz on Obamacare Silences the Room
BYLINE: MATT FLEGENHEIMER
SECTION: US; politics
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HIGHLIGHT: A Hillary Clinton supporter whose brother-in-law, uninsured until the Affordable Care Act, died of cancer, asked Senator Ted Cruz what he would replace the law with if he dismantled it.
HUBBARD, Iowa - Senator Ted Cruz is often asked about doing away with President Obama's health care law. He is less rarely pressed by voters on what will replace it.
But at a middle school cafeteria here, a man, Mike Valde, presented him with a tragic tale. His brother-in-law Mark was a barber - "a small-business man," he said. He had never had a paid vacation day. He received health insurance at last because of the Affordable Care Act. He began to feel sick and went to a doctor.
"He had never been to a doctor for years," Mr. Valde, 63, of Coralville, Iowa, said. "Multiple tumors behind his heart, his liver, his pancreas. And they said, 'We're sorry, sir, there's nothing we can do for you.' "
The room was silent.
"Mark never had health care until Obama care," Mr. Valde continued. "What are you going to replace it with?"
Mr. Cruz expressed condolences and pivoted quickly to a well-worn answer assailing the health care law.
Mr. Cruz said "millions of Americans" had lost their jobs and their doctors as a result of the law, and that many had "seen their premiums skyrocket."
He said he had often joked about a pledge by Mr. Obama that premiums would drop: "Anyone whose premiums have dropped $2,500, as President Obama promised, should vote for Hillary Clinton," Mr. Cruz said. "I'll take everybody else."
Many in the room laughed.
Mr. Valde - who said in an interview later that he did in fact intend to caucus for Mrs. Clinton - pressed on.
"My question is, what are you going to replace it with?" he said.
Mr. Cruz said he was getting there, but had to lay out the problems with the law first. "There are millions of stories on the other side," he said, describing voters who had liked their insurance plans and lost them because the plans did not provide the level of coverage the new law required.
He went on to describe elements of his plan, which includes an effort to allow people to purchase insurance across state lines.
Mr. Cruz turned back to Mr. Valde. "Your father-in-law, he couldn't afford it," he said.
"Brother-in-law," Mr. Valde said.
"Your brother-in-law couldn't afford it," Mr. Cruz said.
"Right," Mr. Valde said. "But he could afford it - he finally got it under Obama."
"He would have gotten it earlier, if he could have afforded it earlier," Mr. Cruz said. "But because of government regulations he couldn't."
Moments later, Mr. Cruz wrapped up and Mr. Valde sat down.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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December 9, 2014 Tuesday
Health Law Adviser Apologizes for 'Stupid' Comments
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 207 words
HIGHLIGHT: Jonathan Gruber, the M.I.T. economist who advised the Obama administration on the Affordable Care Act, apologized on Tuesday for inflammatory comments that have brought negative attention to the law in recent months.
Jonathan Gruber, the Massachusetts Institute of Technology economist who advised the Obama administration on the Affordable Care Act, apologized on Tuesday for inflammatory comments that have brought negative attention to the law in recent months.
In prepared testimony to the House Committee on Oversight and Government Reform, Mr. Gruber said: "I would like to begin by apologizing sincerely for the offending comments that I made. In some cases I made uninformed and glib comments about the political process behind health care reform."
Mr. Gruber stirred controversy when he said in a speech that a lack of transparency and "the stupidity of the American voter" made it possible for the health law to pass. The videos went viral after they surfaced.
While Mr. Gruber was apologetic, he also attempted to distance himself from the law, arguing that he is not a political adviser or a politician.
"I did not draft Governor Romney's health care plan, and I was not the 'architect' of President Obama's health care plan," Mr. Gruber said in his remarks to the committee.
Mr. Gruber said that he ran models to help governments project likely outcomes of policy choices and that his speeches were meant for technical audiences at academic conferences.
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October 7, 2014 Tuesday
Late Edition - Final
Health Plan Cancellations Are Coming, but Not So Many
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 952 words
People are starting to get letters telling them their health insurance plans have been canceled because of the Affordable Care Act. Because the letters will go out just before the midterm congressional elections, they are likely to get a lot of attention. There have been several stories this past week. But the people affected will represent only a small fraction of the population with health insurance.
The cancellations are occurring at the state level, and some insurance regulators don't require any reporting, so a precise head count is difficult. But it appears that as many as several hundred thousand people will find their plans canceled this year. That sounds like a lot of people, but to put it in context: The total number of Americans with health insurance is more than 276 million, according to a recent government survey. The individual insurance market contains about 20 million people, according to estimates from the Kaiser Family Foundation that will be published later this month.
Plan cancellations were a big story last fall, when several million Americans were told that their insurance plans were not compliant with rules established by the Affordable Care Act. The law says that all insurance plans need to cover a minimum set of health benefits and cover a minimum percentage of expected medical bills -- tests that many of the older plans couldn't pass. The plan cancellations were particularly problematic because they coincided with insurance marketplace websites that didn't work, leaving many people without a way to sign up for new insurance options even if they wanted to.
For many of those people, especially those earning high incomes, the new options were more expensive than the plans that were discontinued. But that is not true for everyone. In the new marketplaces, middle-class customers are eligible for tax credits that help them pay for their policies. A survey from the Kaiser Family Foundation this spring found that about 39 percent of people who switched from canceled plans to marketplace plans paid higher rates, though that number does not include people whose plan cancellations caused them to become uninsured.
This year is different for two reasons. One is that the number of cancellations is so much smaller. The other is that, in many cases, the law does not require companies issuing the plans to cancel them.
''The scale and dynamics at play are much different this time around,'' said Claire Krusing, a spokeswoman for America's Health Insurance Plans, an industry group, in an email. ''Discontinuations may be a reflection of state-by-state decisions or a range of dynamics in different markets.''
Last year, the Obama administration opted to postpone enforcement of regulations governing the existing plans, allowing state regulators and individual insurance companies to decide whether to cancel them right away or extend them for up to three years. Some states decided to cancel all the plans last year anyway. Ultimately, it appears that just under two million people had to leave noncompliant plans in 2014, according to an analysis of survey data done by Jon Gabel, a senior fellow at the University of Chicago's research organization NORC.
Of the places that still offer such plans, seven states and the District of Columbia are requiring insurance companies to drop noncompliant plans before the start of 2015, according to a policy summary complied by America's Health Insurance Plans.
Decisions to cancel plans in other states are coming from the insurers offering them, not because of an immediate legal deadline. The companies are simply choosing to stop offering particular products, something they often did even before the passage of the Affordable Care Act. That's what's happening in Kentucky, for example, where the Senate minority leader, Mitch McConnell -- a Republican opposed to the health law and up for re-election -- has circulated a news release about reports of cancellations (''October Surprise'' is the headline).
In a statement, Ben Wakana, a spokesman for the Department of Health and Human Services, noted that consumers whose plans are canceled now have the option to shop for new coverage in state marketplaces. ''As was the case before the Affordable Care Act, private insurance companies operate in a free market: They may choose to discontinue, change and replace plans so long as they let their enrollees know their options,'' he said.
The plan cancellations are part of the design of the health law. The Affordable Care Act set out to reshape the individual insurance market to make plans more comprehensive and fair, with prices less variable by customers' ages and health status. Switching to the new regulatory system meant that some existing products would have to go. That process clearly puts some purchasers of the old policies at a disadvantage, particularly young, healthy and high-income people, who are most likely to face premium increases in the marketplaces.
But historical evidence suggests that the number of people at risk of losing their coverage because of the changes will dwindle substantially over time. Some people in noncompliant plans may choose to switch to the new marketplaces to get a better deal. Others may leave the market because they aged into the Medicare program or got a new job that came with coverage. A study of the individual market before the Affordable Care Act passed found that more than half of the people enrolled in individual market plans in 2011 had left them by 2012.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2014/10/07/upshot/health-plan-cancellations-are-coming-but-for-relatively-few.html
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February 26, 2017 Sunday
Late Edition - Final
Key Foe of Health Law Hails From State That Embraced It
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 1434 words
ONTARIO, Ore. -- When Representative Greg Walden of Oregon visits his expansive district, which swallows two-thirds of a very blue West Coast state, his constituents grouse amiably to their longtime Republican congressman about environmental regulations and federal lands policy.
And then the conversation shifts to the Affordable Care Act and what its repeal would mean for the struggling rural workers who have long voted for Mr. Walden, and for children like 11-year-old Rocco Stone. Because of the health law, Rocco has been able to live at home, attend school and have a nearly normal life despite having autism and a rare genetic disorder.
''Our life was completely changed when Oregon and the federal government partnered to provide home and community services through Medicaid,'' Rocco's mother, Dana M. Stone, told the congressman this past week. ''We are deeply, deeply concerned about talk at the federal level about a complete repeal of the Affordable Care Act.''
Mr. Walden, the new chairman of the House Energy and Commerce Committee, is not just another backbench Republican dealing with suddenly energized supporters of the health law at town hall-style meetings. The lanky 60-year-old congressman will have a large role in drafting promised legislation to replace former President Barack Obama's signature domestic achievement and a huge say in decisions about the future of Medicaid, which the health law greatly expanded.
As a former chairman of the committee responsible for electing Republicans to the House, Mr. Walden knows the politics of health care as well as anyone. But in his new role, he must reconcile the political goals of his party, which is committed to repealing the 2010 health law, and the interests of his state, where officials say the law has been a big success. In 2010, nearly one in five Oregonians lacked health coverage. Today, state officials say, 95 percent of Oregonians have coverage.
Since Oregon expanded eligibility for Medicaid under the health law in 2014, enrollment has increased more than 65 percent. Nearly one-fourth of the state's four million residents are now on Medicaid.
In Mr. Walden's district, the percentages are even higher. In some of his rural counties, more than one-third of the people are on Medicaid. President Trump easily carried those counties. Mr. Walden won a 10th term in the fall with 72 percent of the vote and was victorious in every one of the 20 counties in his district, which is about the size of New York, New Jersey and Connecticut combined.
But that does not guarantee that voters here endorse all the policies of his party. Hospitals are among the leading supporters and beneficiaries of Affordable Care Act. Mr. Walden was a trustee of a 25-bed hospital in his hometown, Hood River.
''We are very worried about what 'repeal and replace' might look like,'' said David Underriner, who supervises the hospital, Providence Hood River Memorial, as Oregon's regional chief executive for Providence Health and Services, the large Roman Catholic system that owns it.
Mr. Walden grew up on a cherry orchard, worked at radio stations owned by his family, and followed his father into the State Legislature. The political shifts that have turned all three Pacific Coast states reliably Democratic have begun to creep into a few of the conservative inland parts of Oregon. Hood River County, long known for fruit farming, windsurfing and the spectacular scenery of the Columbia River Gorge, has lately become a center for the production of surveillance drones, leading to an influx of software engineers, technology entrepreneurs and other young professionals.
Mr. Walden's margin of victory in November in the county where he lives was just five votes -- out of more than 10,590 cast.
''It's just a little left-leaning,'' Mr. Walden allowed. ''It didn't used to be that way.''
Unlike many Republicans in Congress, Mr. Walden has worked productively with Democrats. ''I'm a problem solver,'' he said in an interview after a town hall-style meeting here near the Idaho border. ''I'm not an ideologue. I want to fix things.''
And in Oregon, some Democrats and health-law supporters are glad Mr. Walden is in his position.
''I've known Greg a long time,'' said Andrew S. Davidson, the president and chief executive of the Oregon Association of Hospitals and Health Systems. ''He is not interested in upending the progress we have made in this state.''
Representative Kurt Schrader, a Democrat whose district includes the southern suburbs of Portland and the capital, Salem, predicted Mr. Walden ''will be mindful of the implications of any legislation for our state, which is leading the nation in the transformation of health care.''
Unlike Mr. Walden, Oregon has embraced the Affordable Care Act. State officials say many of the changes proposed by congressional Republicans, including a rollback of federal funds for the expansion of Medicaid, would reverse much of the progress they have made.
Oregon has a history of health care innovation that predates the Affordable Care Act. In the early 1990s, it ranked medical procedures according to their costs and benefits, and Medicaid uses this list to decide which services to cover. Under a federal waiver granted in 2012, Oregon treats Medicaid beneficiaries through 16 ''coordinated care organizations,'' which are governed by local citizen councils. The organizations have slowed the growth of health spending and improved the health of Medicaid beneficiaries, according to performance data collected by the state.
Even as he writes legislation to unwind the Affordable Care Act, Mr. Walden takes pride in Oregon's success under the law.
''Our state of Oregon has had quite a bit of innovation over the years,'' Mr. Walden said. ''We've got the coordinated care organizations in place that have actually brought better health care outcomes at lower cost. There are great ideas out there among the states, but right now, they have to come back and beg permission from a federal bureaucrat to be able to do much of anything innovative.''
When Mr. Walden first ran for Congress in 1998, conservatives called him too liberal. Since then, he has taken more conservative positions, and the party has moved to the right.
''Times change,'' he said. ''You get a terrorist attack. You have different administrations come and go. Culture changes. My bedrock principles have stayed the same. I favor more local decision-making and less Washington decision-making.''
Mr. Walden never wavered in his opposition to the Affordable Care Act. On the day the House passed the bill in March 2010, he and other Republicans stood on the Capitol balcony, before a throng of protesters, and held up signs with handwritten letters that spelled out their message: ''Kill the Bill.''
A month later, on the House floor, Mr. Walden announced the goal that he hopes soon to achieve, using words that became the mantra for Republicans: ''We need to repeal and replace this law.''
Over the last four years, Mr. Walden has been a genial attack dog for Republicans. As chairman of the National Republican Congressional Committee, he averted a political blood bath for his party and secured the election of Republicans in many districts that voted for Hillary Clinton in the presidential election. Many of those House campaigns revolved around attacks on the health law that he is now charged with replacing.
Oregon tried to run its own health insurance exchange, but had a disastrous experience and decided, after a year, to use the federal website, HealthCare.gov. The state has a competitive insurance market, but consumers have still seen substantial increases in prices, with the average premium for a popular benchmark plan on the exchange rising 27 percent this year and more than 20 percent last year, according to the federal government. (Subsidies cushion the impact for most consumers.)
''Medicaid did better than expected, and subsidized commercial insurance did worse,'' said Dennis E. Burke, the president of the Good Shepherd Health Care System in Hermiston, Ore. ''We have seen steep increases in premiums for commercial insurers, and as a result healthy people have dropped out.''
People newly covered under the health law ''proudly present an insurance card,'' Mr. Burke said, but in many cases their plans have high deductibles, and the hospital has difficulty collecting the patient's share of the bill.
But Mr. Burke is not so quick as his congressman, Mr. Walden, to seek repeal.
''I think it could be fixed,'' Mr. Burke said. ''We need more of a retooling.''
URL: http://www.nytimes.com/2017/02/25/us/politics/oregon-republican-representative-affordable-care-act.html
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GRAPHIC: PHOTOS: Representative Greg Walden, leader of the Energy and Commerce Committee, last week with a constituent, above, in La Grande, Ore., and at a forum, left, in Ontario, Ore. (PHOTOGRAPHS BY TODD MEIER FOR THE NEW YORK TIMES)
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The New York Times
November 11, 2016 Friday 00:00 EST
Morning Agenda: A Fresh Wave of Deals Ahead
BYLINE: AMIE TSANG
SECTION: BUSINESS; dealbook
LENGTH: 697 words
HIGHLIGHT: Mergers and acquisitions could be on the rise, driven by changes to taxes, as well as shifts on the Dodd-Frank Act and the Affordable Care Act.
The United States president-elect didn't write a book called "The Art of the Deal" for nothing.
It now looks like mergers and acquisitions could be on the rise, providing Donald J. Trump's administration can govern with stability.
Deal making could be encouraged (or, indeed, reduced) by changes to taxes, as well as shifts on the Dodd-Frank Act or the Affordable Care Act.
There are huge changes coming that could markedly alter how the economy functions - for better or worse. Either way, companies will be angling to reposition themselves, which is likely to keep driving deal-making momentum.
His pro-business tendencies (let's not forget that he is a real estate developer) may also be a boon for investors.
Mr. Trump's promise to make a push on infrastructure spending has bolstered stocks in construction companies.
The prospect of deregulation could also rally shares in banks, pharmaceuticals and energy. It seems that now that the initial uncertainty of the election result is over with, there could be gains ahead for stocks.
Quotations of the Day From the DealBook Conference
Executives and other leaders grappled onstage with the results of the election. Here's what they had to say.
"We are going to get a lot done."
- William A. Ackman, the hedge fund manager, on feeling bullish about a Trump presidency and liking the idea that the president-elect would run the country like a business. He also admitted that he might have been better not going public with his call on Herbalife, which he accused of being a pyramid scheme.
"He would be a great Treasury secretary."
- Lloyd Blankfein, the chief executive of Goldman Sachs, on reports indicating that Mr. Trump was considering JPMorgan's chief executive, Jamie Dimon, for the role.
"Scale matters because it is going to give us leverage and we are going to need leverage with some partners."
- Shari Redstone, whose family controls CBS and Viacom, making the case for merging the two companies.
"I got a picture this morning of a swastika."
- Howard Schultz, the chief executive of Starbucks, on disturbing images he had seen in the aftermath of the election. Mr. Schultz was an outspoken supporter of Hillary Clinton.
"No one is telling a writer, 'Write this based on the data.' "
- Richard Plepler, the chief executive of HBO, on why the viewer data collected by HBO (and eventually used by AT&T if a deal with Time Warner were completed) would not be used to dictate the kinds of shows being made.
"Forget the Pepsi brand - how dare we talk about women that way? Why do we talk that way about a whole group of citizens?"
- Indra Nooyi, the chief executive of PepsiCo, on the coarse language used during the election and the domestic violence issues confronting the National Football League, which is sponsored by Pepsi.
"When the conversation comes to the point of reality, I think it's going to be a very different conversation."
- Sylvia Mathews Burwell, the United States secretary of health and human services, on the prospect of changes to the health care law.
"You can't put them out on the street without insurance."
- Mark T. Bertolini, the chief executive of Aetna, on the 20 million people who gained health care coverage through the Affordable Care Act, and why he thinks parts of the law will endure.
"China has been responsible for the vast majority of commercial attacks, and yet we maintain good relations with China over all."
- Eric Schmidt, the executive chairman of Alphabet, said that the United States government had not yet figured out how to deter digital attacks from other countries.
Coming Up
Stanley Fischer, the vice chairman of the Federal Reserve, speaks about United States monetary policy and the global economy at the 20th annual conference of the central bank of Chile.
Alibaba's shopping holiday, Singles Day, draws to a close. With growth in users, new stores and the value of goods sold on its platform slowing, it looks like the very dynamics that helped Alibaba engineer the holiday have turned against it.
Follow Amie Tsang on Twitter @amietsang.
Related Articles
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Trump's Policies May Bring Fresh Wave of Deals
Trump's Victory Bodes Well for Investors - for Now
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November 14, 2014 Friday
Consumers Satisfied With Health Exchanges, Poll Finds
BYLINE: ALAN RAPPEPORT
SECTION: US; politics
LENGTH: 235 words
HIGHLIGHT: Consumers who bought health insurance through the Affordable Care Act exchanges say they are satisfied with their purchases.
The Affordable Care Act's second enrollment period, which begins this weekend, has been ushered in with a litany of criticism about everything from rate hikes to old comments from one of the people who helped craft the law.
But the consumers who actually bought insurance through the new law seem pretty happy with it.
According to a new poll from Gallup, seven out of 10 Americans who bought health insurance through government exchanges in the last year thought the quality of their care and coverage was "good" or "excellent."
Those who bought insurance through the exchanges also appear to be more satisfied with the cost of their coverage than people who got insurance by other means. Gallup's analysis suggests that this is probably because many people who bought insurance through the exchanges received government subsidies, making their coverage relatively inexpensive.
The survey found that 68 percent of people who bought insurance through an exchange will renew their current policy, while 7 percent will change policies but still make the purchase through an exchange.
Four percent of the adult population in the United States bought insurance through the exchanges last year.
Be sure to take a look at The Times's story on the challenge the Obama administration is facing to get people to re-enroll for insurance during the three-month window.
Health Care Act Faces Major Test: Getting Users to Re-enroll
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June 26, 2015 Friday
Late Edition - Final
A President Again Triumphs in a Bruising Battle for His Legacy
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; NEWS ANALYSIS; Pg. 16
LENGTH: 1200 words
WASHINGTON -- For years, President Obama has faced the sneers of political adversaries who called his health care law Obamacare and assailed his effort to build a legacy that has been the aspiration of every Democratic president since Harry S. Truman.
But on Thursday, Mr. Obama walked into the Rose Garden to accept vindication as the Supreme Court, for a second time, affirmed the legality of a part of the Affordable Care Act. Mr. Obama said the law ''is working exactly as it's supposed to'' and called for an end to the vitriolic politics that have threatened it.
''The point is, this is not an abstract thing anymore,'' Mr. Obama told reporters, with Vice President Joseph R. Biden Jr. smiling broadly beside him. ''This is not a set of political talking points. For all the misinformation campaigns, all the doomsday predictions, all the talk of death panels and job destruction, for all the repeal attempts -- this law is now helping tens of millions of Americans.''
Mr. Obama's plea to stop ''refighting battles that have been settled again and again and again'' met on Thursday with immediate resistance. House Speaker John A. Boehner, Republican of Ohio, promised to ''do everything we can'' to undermine the law. Jeb Bush, a Republican candidate for president, vowed ''to repeal and replace this flawed law'' if he succeeds Mr. Obama in the Oval Office.
Mr. Boehner said he will continue to move forward with a lawsuit against the president that argues that Mr. Obama overstepped his legal authority in carrying out the health care act, although the case is in its early stages at the district court level and could take years to come before the Supreme Court. Other Republicans mused on Thursday about using parliamentary maneuvers to chip away at the law.
But for Mr. Obama, the ruling was a personal affirmation of the wisdom of engaging in a costly political fight that began almost as soon as he took office. The court's ruling, Mr. Obama said Thursday, cements the Affordable Care Act in American history as the logical extension of Social Security and Medicare.
''This generation of Americans chose to finish the job,'' Mr. Obama said, reading from one of two sets of remarks -- one written as if the Supreme Court upheld the subsidies and another as if the court did not. Cody Keenan, Mr. Obama's chief speechwriter, had prepared both sets before the court announced its decision.
Once the decision was announced, and just before walking into the Rose Garden, Mr. Obama signed the set of remarks for Mr. Keenan that were written as if the court had ruled against the administration. ''Didn't need this one, brother!'' Mr. Obama scrawled across the bottom.
The White House soon released photographs of Mr. Obama and Denis McDonough, the president's chief of staff, performing celebratory fist pumps outside the Oval Office.
The court ruling came as Mr. Obama is heading toward another major legislative accomplishment, the passage of powerful new authority that will allow him to finish negotiations on a historic trade agreement with Pacific Rim nations. That bill, which he pushed over the objections of many in his party, will be on his desk for his signature this week.
But the Supreme Court decision is the bigger victory at home for Mr. Obama, whose domestic policy legacy has always depended on the Affordable Care Act's becoming a permanent part of the American health care system by the time he leaves office in 2017.
Unable to halt the implementation of the law in Congress, Republican lawmakers, governors and others turned to the courts, betting that successful legal challenges would prevent Mr. Obama from establishing the Affordable Care Act as an accepted companion to Medicare and Medicaid.
Instead, the two main legal challenges to the law have largely failed. In 2012, the Supreme Court slowed the law's expansion of Medicaid, but let stand the individual mandate that requires people to purchase health insurance. And in Thursday's ruling, the court said the federal government could provide subsidies to people purchasing coverage through a federal insurance marketplace.
The court decision ended months of speculation and worries among administration officials, health experts, lawmakers from both parties and insurance company executives about the potential for chaos in the insurance markets if the justices had gone the other way.
Officials had predicted a cascading series of events if the subsidies were invalidated: Premiums for millions of people would have doubled or tripled. That would have forced many to drop insurance altogether, causing insurance companies to drastically raise rates or stop selling plans. In the worst-case scenario, officials predicted a collapse of the individual health insurance market in many states.
Republicans said they would have welcomed such a ruling because it would have forced Mr. Obama to negotiate with them and, they hoped, to abandon the Affordable Care Act for something more to the liking of conservatives. Mr. Obama had repeatedly said that Republicans -- who supported the filing of the court case -- would be responsible for addressing the effect if the court ruled against the administration.
The court's decision means that Mr. Obama's administration will continue to enroll people in private, but subsidized, health insurance. About 10 million people have already bought insurance from state or federal marketplaces. Officials are hoping to enroll millions more by the time the president's term ends.
Despite writing the decision, Chief Justice John Roberts also made a point of chiding the lawmakers who drafted the law and, by association, the president who pushed them to do it.
Early in his tenure, the president had said he hoped for bipartisan cooperation on fashioning a new approach to health care that would lower costs for the government while providing health coverage to the tens of millions of uninsured Americans. But when the Republicans balked, the Democrats -- who then held majorities in the House and Senate -- went ahead and passed the law.
Chief Justice Roberts said it would be ''charitable'' to accuse the authors of ''imprecision,'' and noted that the bill was written in secret and passed with special parliamentary procedures that limited opportunities for input or revision. He said the resulting law ''does not reflect the kind of care and deliberation that one might expect of such significant legislation.''
Chief Justice Roberts quoted a 1947 lecture by Justice Felix Frankfurter, in which he refers to a cartoon of a senator telling his colleagues: ''I admit this new bill is too complicated to understand. We'll just have to pass it to find out what it means.'' It appeared to be a pointed allusion to a statement then-House Speaker Nancy Pelosi made about the health care legislation, which is often cited derisively by Republicans as proof that the measure was rammed through without proper consideration.
But, Chief Justice Roberts added, ''Despite all that, we must do our best to understand the statute as a whole.''
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February 22, 2015 Sunday
Late Edition - Final
For Tens of Millions, Obamacare Is Working
BYLINE: By STEVEN RATTNER.
A contributing opinion writer and a Wall Street executive.
SECTION: Section SR; Column 0; Sunday Review Desk; CONTRIBUTING OP-ED WRITER; Pg. 5
LENGTH: 626 words
Ever since President Obama unveiled his health care plan in 2009, critics have questioned its lofty promise to bring affordable health insurance to millions of Americans.
Now statistics for the second year are largely in hand and the verdict is indisputable: Its disastrous 2013 rollout notwithstanding, the Affordable Care Act has achieved nearly all of its ambitious goals.
Most important, just three key provisions -- creation of exchanges with subsidies for those who qualify, expansion of Medicaid and minimum standards for insurance plans -- have benefited at least 31 million Americans.
Millions more have taken advantage of other features, such as the inability of insurance companies to deny coverage based on pre-existing conditions and the ability to include children up to age 26 in a parent's plan.
Finally, while other promises of the Affordable Care Act are harder to measure, the slowdown in the rate of increase in health care costs and health insurance premium prices is at least partly due to the new law.
The program still faces challenges -- notably a Supreme Court decision on subsidies expected by June that has the potential to undermine the program in many states. There are disappointments, too; millions of Americans faced higher premiums after being forced off substandard plans. Nonetheless, the law's cornerstone role in our health care system now seems assured.
At least 13.4 million Americans -- more than the population of Illinois -- have been added to the insurance rolls. The ranks of the uninsured, which stood at more than 42 million before the law's passage, have thus fallen by almost 30 percent.
A second indicator of success are the 11.4 million people who have signed up thus far -- stragglers will increase the final tally -- to buy insurance on the exchanges, which provide greater transparency for consumers and competition among providers, as well as subsidies for purchasers with incomes up to $95,400 for a family of four. (About 12 percent of enrollees will be likely to drop out by not paying the first premium, but the ultimate number should be at least 10 million.)
The president's program also required that all insurance plans meet minimum standards of coverage. An estimated eight million Americans will benefit from this provision in 2015 by receiving upgraded benefits.
After being told by the president that ''if you like the plan you have, you can keep it,'' approximately 7.5 million people left substandard plans, many of them involuntarily. Their justified unhappiness was cacophonous.
A large reduction in the number of uninsured people came from expanding Medicaid to cover those who are slightly higher on the income scale previously used for the program (up to $33,465 for a family of four). Because 22 predominantly Republican states have declined to join in this expansion, participation is below initial forecasts. However, the number of states holding out has been gradually declining because of public pressure. (''Woodworkers'' refer to roughly 3.3 million people who were already eligible to participate in Medicaid but came out of the ''woodwork'' only as a result of the new law.)
Americans age 65 and older are covered under Medicare, so the new law has no meaningful impact on those enrollments. The increase of one million stems from an aging population.
The creation of the exchanges provided some encouragement for employers to drop coverage, particularly if their plans did not meet the new standards. Over the next three years, that falloff is expected to grow to nine million, still small in relation to the 39 million people projected to be added under the law.
This is a more complete version of the story than the one that appeared in print.
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GRAPHIC: GRAPHICS: Six Groups of Americans and How They Are Faring (Source: ACASignups.net)
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The New York Times
January 20, 2017 Friday 00:00 EST
Friday Mailbag: Soda, the Health Act and 'Mrs.' Trump;
The Public Editor
BYLINE: LIZ SPAYD with EVAN GERSHKOVICH
SECTION: PUBLIC-EDITOR
LENGTH: 1587 words
HIGHLIGHT: Did The Times hold low-income people to a double standard when it wrote about food stamps and soda purchases?
Whether because of the open enrollment period in insurance or the looming decision on the Affordable Care Act, health was on Times readers' minds this week. One article specifically, in the Well section, drew the most heat from readers.
The story, on a U.S.D.A. report describing the purchasing habits of families that get government food aid, was framed as a look inside the shopping cart of a food stamp household. But as many readers noted, what the story minimized was the fact that both households that are in the Supplemental Nutrition Assistance Program (known as SNAP) and those that are not make similar purchases. Further down in the piece:
The report compared SNAP households and non-SNAP households. While those who used food stamps bought slightly more junk food and fewer vegetables, both SNAP and non-SNAP households bought ample amounts of sweetened drinks, candy, ice cream and potato chips. Among non-SNAP households, for example, soft drinks ranked second on the list of food purchases, behind milk.
Here are several reader notes in response to the story:
As a woman who was never on the SNAP Program, I find the title especially insulting to anyone on food stamps. You mention in the article that both SNAP and non-SNAP shoppers buy comparable amounts of junk food, so why was it necessary to single out those who are on the SNAP Program?
Diane Cebzanov, Ellenburg, N.Y.
If SNAP households have the same buying habits as other households, why aren't the drinking patterns of those other households of concern? We are constantly inundated with reports of obesity epidemics and preventable diseases across the spectrum of consumers, and here we have proof that the poor eat basically the way the rest do. But the article suggests only SNAP recipients should be prohibited from buying sugary drinks to prevent disease, while ignoring the heavy subsidies given to the sugar industry and the corn industry, the removal of which could help health outcomes of all demographics.
Debi Riggs Shaw, Paupack, Pa.
You have speciously and stereotypically implied that poor people are stupid in their consumer purchases and habits whereas the actual story reports how most consumers of any stripe buy too many snack foods including accursed sodas.
Helen Moshak, Evanston, Ill.
Here's a journalist responding to the piece on Twitter:
That @nytimes headline should be that @USDA found little difference between SNAP and non-SNAP grocery carts. That's the news peg. - Marissa Evans (@marissaaevans) January 14, 2017
And here's a former Times reporter:
This story is shaming food-stamp recipients for buying the same stuff all families do. https://t.co/60fzdpFHoR - Annie Lowrey (@AnnieLowrey) January 14, 2017
We went to Tara Parker-Pope, the editor of Well, for a response. She says the issue raised by readers - that people in most U.S. households, not just poor people, buy a lot of soda, sweetened beverages and junk food - was "a central theme in the story, and not only did we make sure it was addressed high in the story, it was an ongoing theme in the middle and end of the story as well." She added, "That said, it's a matter of discussion and debate whether a federally subsidized food program, designed to improve the nutrition of poor people, should allow junk food and soda just because everyone else eats it."
The public editor's take: I side with the readers on this one. It's true that the article mentioned - well into the story - that households overall purchase about the same amount of sweetened drinks as SNAP households, but that wasn't the way the story was framed. Furthermore, headlines matter, and this one said: "In the Shopping Cart of a Food Stamp Household: Lots of Soda." That's fairly loaded. And then there was that photograph of a shopping cart filled almost entirely with soda. (In fact, the story noted, 5 percent of the SNAP dollars spent on food goes to soft drinks.) The cutline under the photo? "A government report shows that sugary soda is the most popular item in the shopping carts of families that receive federal food stamps." The purchases of food stamp households is a long-debated subject in political and policy circles. This piece didn't do much to advance the discussion.
Staying on the popular topic of health, several readers took issue with The Times referring to the Affordable Care Act as Obamacare, arguing that the issue is too fraught to attach Obama's name to the law.
Referring to the Affordable Care Act as Obamacare plays into the hands of the conservative right who have weaponized that shorthand label. (Remember Hillarycare?) Only using the health care law's rightful name is a small but responsible journalistic response to the current Republican assault.
Harriet Watson, Portland, Ore.
There has been vacillation, however, over what to call the act, often among Democrats themselves, depending on its popularity. In 2013, President Obama affirmed he wanted the law to be referred to by his name. "We passed Obamacare - yes, I like the term - we passed it because I do care, and I want to put these choices in your hands where they belong," he said.
We asked Phil Corbett, the associate managing editor for standards, for his take.
Most often in straight news stories we refer to the law by its formal name, the Affordable Care Act, or simply with a generic description like "President Obama's health-care law." Early on, we studiously avoided "Obamacare" because it was used primarily as a derogatory name, by critics, and seemed politically loaded to us.
I think that "loaded" quality has long since faded, since people on all sides of the debate now routinely use the nickname "Obamacare." We still generally avoid it in straight-news stories from Washington, because we generally don't use a lot of nicknames or colloquial terms in those stories. But The Upshot has always adopted a more informal, conversational tone, so we decided a long time ago that "Obamacare" was O.K. in that context.
One story on Obamacare caught readers' attention on account of its headline, which read: "Trump Promises 'Insurance for Everybody' as Health Law Replacement."
I was dismayed to see the uncritical headline. Not until the fourth paragraph does the article mention that he offered absolutely no details for this plan. I see this kind of headline as a gift to the president-elect, allowing him to broadcast vague promises without accountability. Please don't make it so easy for Trump to manipulate the media.
Jenny Davis, Belfast, Me.
With Donald Trump's inauguration taking place today, it's as good a time as any to remind journalists to stay vigilant in holding him accountable.
Another reader noted that the reporting on Volkswagen's diesel scandal could use a deeper look in one area.
I am writing about the coverage of the Volkswagen diesel scandal and settlement. Jack Ewing and Neal Boudette have done some good reporting, especially on the criminal aspects of this case. But what I find lacking is any coverage - and, indeed, investigation - into the progress of the buyback program for those of us who are personally impacted by this scandal. I am the owner of a 2013 VW Passat TDI and a verified claimant in the litigation who has chosen to have VW buyback my vehicle. The court settlement was reached on October 18 and we were promised a quick turnaround, within weeks, to receive our buyback. Two months have passed and we have heard nothing, let alone received our settlement money. Calling the "VW Claimant Line" to get information is an exercise in frustration. After several calls recently I finally spoke with a representative who confessed that they are way behind schedule. I and others want to know what is going on. We have little recourse to complain and no media outlet seems to be investigating this delay.
The Rev. Dr. Scott P. Albergate, Havertown, Pa.
After we passed the note along to one of those reporters, Ewing, The Times's European economics correspondent, he told us that this is indeed something the paper should be writing about. He also said:
The Volkswagen case has generated a lot of mail and often tells me something I didn't know. It was through readers early in the case that I realized how effectively Volkswagen sold to environmentally conscious buyers, who were then extra mad to learn about the cheating. More recently I've gotten a few letters from people having problems with the buyback process, although others have told me it's going well. As always there is an issue of reporter bandwidth.
Finally, The Times has found some closure with respect to the new first lady's courtesy title. Last July, the public editor addressed why some women are referred to as "Ms.," including Melania Trump, and some as "Mrs." The public editor noted that Melania Trump had "yet to express a preference (thus the default 'Ms.,' although reporters have been asked to determine her preference)."
Now, however, the senior editor for standards, Greg Brock, tells the newsroom that the next first lady has expressed a preference: henceforth she will be referred to as Mrs. Trump in The Times's pages.
Except in this column, of course, where we have done away with titles. She'll be just "Trump." And as for us, you can still call us Spayd and Gershkovich.
Each Friday, Evan Gershkovich, in the office of public editor Liz Spayd, surfaces some of the more thoughtful and provocative complaints that come in - some of which are edited for clarity and length. To be featured here, email the public editor at public@nytimes.com. Follow the public editor on Twitter @spaydl.
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The New York Times
March 22, 2015 Sunday
Late Edition - Final
Under Health Act, Many Tax Filers Are Discovering Costly Complications
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1206 words
PITTSBURGH -- When he signed up for health insurance through the Affordable Care Act last fall, J. C. Ciesielski estimated his income at $19,400, qualifying him for a federal subsidy that cut his premiums in half. But Mr. Ciesielski, an actor, earned an extra $2,340 from a voice-over job in December, and that welcome bit of income proved problematic when he did his taxes this month.
A tax preparer told Mr. Ciesielski that because he had not informed the federal health insurance marketplace, HealthCare.gov, of his additional income, he had to repay $118 of his subsidy. Mr. Ciesielski, who is being treated for a brain tumor, looked perplexed as he learned the money would come out of his refund check.
''This is definitely the lowest refund I've ever gotten,'' Mr. Ciesielski, 34, said as he drummed his fingers on the tax preparer's desk. ''But it boils down to I have health insurance, which I desperately need.''
This filing season, for the first time, millions of Americans are facing tax implications -- and new forms that even seasoned preparers are finding confusing -- related to their health insurance status. The changes are not only complicating things for tax filers, but also costing many of them money.
Under the Affordable Care Act, people who remained uninsured last year must either pay a penalty with their taxes, one of the most contentious elements of the law, or claim an exemption. The Obama administration has said up to six million people would owe a penalty of $95 or 1 percent of their household income, whichever is greater. But as many as 30 million people are getting exemptions, mainly because they are too poor to afford health insurance or because they live in a state that refused to expand Medicaid last year under the health law.
And people who did get insurance but, like Mr. Ciesielski, underestimated their income for 2014 -- the figure on which subsidies are calculated -- are being required to pay back part of their subsidy.
In late February, H & R Block reported that its uninsured clients had paid an average penalty of $172. The money comes out of refunds, while people who do not get refunds are required to pay the Internal Revenue Service by April 15.
The health law prohibits the I.R.S. from imposing criminal fines or putting liens on the property of people who ignore the insurance mandate, but it does allow the agency to collect the penalty by reducing future refunds.
''It will still be on their books,'' said Courtenay Murphy, a tax preparer in Gunnison, Colo.
H & R Block also found that as of Feb. 24, just over half of its clients with subsidized marketplace coverage had to repay a portion of their subsidy because their 2014 income turned out to be higher than what they estimated when they applied for coverage.
Kathy Pickering, executive director of the Tax Institute at H & R Block, said these clients had owed back $530 on average, decreasing their tax refund by an average of 17 percent.
''That's pretty significant,'' she said. ''It shows how difficult it is for someone to estimate their income on a looking-forward basis.''
At Just Harvest, a nonprofit group that offers free tax preparation for lower-income people in Pittsburgh, many clients count on their annual refund to cover heating and other basic expenses or to pay down debt.
And while President Obama signed the Affordable Care Act into law five years ago this month, many people still have only a vague understanding of the penalty for not having insurance.
''Many of them know that there's something bad that happens when they don't have health insurance, but they're not quite ready for it,'' said Samuel Mudrak, a volunteer tax preparer. ''They're coming in expecting to get the same refund that they got last year.''
That was the case for Mark Taylor of Carroll, Iowa, who was surprised to owe a $95 fine with his taxes because his wife, Barbara, remained uninsured last year. Other members of his family were fined, too, he said, and some were irate.
''I've got a cousin, he called me up and said, 'How bad did you get socked?' '' Mr. Taylor, 52, said. ''We think it's ridiculous.''
Nonetheless, in Mr. Taylor's case, the penalty worked as a nudge: After doing his taxes, he hustled to buy coverage for his wife in order to avoid a much bigger penalty -- at least $325 -- at tax time next year.
Others threatened with a penalty have discovered they did not owe one. Josephine Kennedy, for instance, had worked a series of low-paying jobs in 2014 and had gone without health insurance, despite the new Affordable Care Act requirement that most Americans get coverage.
''I don't understand where all of this is coming from,'' Ms. Kennedy, 51, said, shaking her head as she waited for a tax preparer at Just Harvest in Pittsburgh to tell how big a penalty she would owe.
But Ms. Kennedy, now a housekeeper at a private business club, ended up owing no penalty. With an income of $12,563, she would have qualified for Medicaid if Pennsylvania had expanded the program, an option allowed by the Affordable Care Act, last year. Since it did not, she got an exemption from the penalty.
The state has now expanded Medicaid, and Ms. Kennedy said she would apply even though she preferred the free clinic she had gone to for years. If she remains uninsured, she will most likely be subject to the penalty for 2015, which will grow to $325 per adult or 2 percent of household income, whichever is larger.
''I still don't see the point of forcing someone to get insurance,'' Ms. Kennedy said. ''But I'm happy I got this taken care of for now.''
People who learn they have to pay back part of their subsidy after underestimating their 2014 income on their insurance application are equally perplexed. Many saw their circumstances change during the year -- getting a job or a raise as the economy improved, for example. But if they failed to report an income change, they will owe the I.R.S.
Mr. Ciesielski, who is on disability, said he would think twice about taking on acting jobs this year to avoid the same predicament when he files his 2015 taxes.
''It's kind of hard to guess'' what his income will be, he said.
As if taxpayers were not confused enough, the federal marketplace sent out forms containing inaccurate data to 820,000 people with subsidized insurance policies in January. Marketplace officials said Friday that they had mailed corrected forms to all but 80,000 of the affected taxpayers, who need them for calculating whether they received an appropriate subsidy.
Those who filed their taxes before the mistake was caught -- about 50,000 people, the Obama administration has said -- do not have to refile, but they could lose subsidy money they are owed.
Laurel Dickenson of Duluth, Ga., is among those people. She was surprised to learn while doing her taxes that she owed back $600 of her insurance subsidy. Now she is waiting for a corrected form and hoping that she may in fact owe less, even though she got a job after becoming insured last spring and did not report her income change.
''I guess I shouldn't have been surprised,'' said Ms. Dickenson, 57, who recently became unemployed again. ''But this is complicated, and it's affecting people's lives.''
URL: http://www.nytimes.com/2015/03/22/us/affordable-care-act-insurance-tax-penalty.html
LOAD-DATE: March 22, 2015
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GRAPHIC: PHOTO: J. C. Ciesielski, left, with Richard Matthews, at a Just Harvest tax center in Pittsburgh. Mr. Ciesielski had to repay part of his health care subsidy. (PHOTOGRAPH BY JEFF SWENSEN FOR THE NEW YORK TIMES)
PUBLICATION-TYPE: Newspaper
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The New York Times Blogs
(The Public Editor's Journal)
October 8, 2013 Tuesday
'Obamacare' - With or Without Quotation Marks
BYLINE: MARGARET SULLIVAN
SECTION: OPINION
LENGTH: 565 words
HIGHLIGHT: A reader raises a question about The Times’s guidelines and procedures for using what some consider a politically fraught term.
A Times reader, Tom Bird, of East Lansing, Mich., raised a timely issue, given all that's happening in Washington. He wrote that other news organizations, including The Associated Press, are putting the expression "Obamacare" in quotation marks, "signifying that it is not a neutral expression, but instead is political rhetoric that is being used in a partisan way." And he added, "When will The Times wake up?"
A quick search of Times news stories turned up only one recent example of the phrase being used in the manner Mr. Bird mentioned. It came in a prototypically Times-like headline on the front of the Sunday business section: "On the Threshold of Obamacare, Warily." (The word also appears regularly, without quotes, on the Economix blog where one recent headline read: "How to Gut Obamacare.")
But, for the most part, the news pages are using what I view as the equivalent of quotation marks - a description of the phrase, which provides the same kind of distance as quotation marks would. Here's an example:
... federal officials declined to discuss whether they had found design flaws in their system, but their comments appeared to place most of the blame on the sheer volume of traffic. They pronounced themselves pleased, saying that the intense interest showed a pent-up demand that demonstrated the need for the Affordable Care Act, the 2010 law known as Obamacare, which created the exchanges.
I asked Philip B. Corbett, the associate managing editor for standards, about the guidelines for the expression in the news pages. "For the most part, we have not used 'Obamacare' as our standard term in news stories outside of quotations," he said. "Aside from the question of whether it's politically charged, the term strikes me as informal - essentially a nickname - which is not our normal style for straight news articles. Most often we simply use a straightforward description, like 'the health care law' or 'the health care overhaul,' or occasionally the formal name, the Affordable Care Act."
However, in the opinion pages of The Times, where different style guidelines often apply, many examples crop up of Obamacare without quotation marks or description. Columnists including Frank Bruni, Charles Blow and Paul Krugman have used the phrase - acceptably, I think - in the context of their overall viewpoints and individual voices.
A reader, Paul Teichert, in mentioning a Joe Nocera column in which the phrase was used, expressed his displeasure: "Why become part of the conservative media echo chamber?" he wrote. "I wish that in future The Times would adopt a policy of calling it solely the Affordable Care Act rather than sounding like those who have disdain for the act and our president."
As for just how politically charged the phrase is, that can be debated. A look back to last year found a Times article about leading Democrats' change of heart in embracing the term. Even the president seemed to be picking it up.
Of course, that was then. Just last week, the ABC talk show host Jimmy Kimmel sent a camera crew out to the streets to query citizens about whether they preferred Obamacare or the Affordable Care Act. They may mean one and the same thing, but people reacted negatively to the first and more positively to the second.
That's far from a scientific poll, of course, but it makes the point that - as The Times's readers point out - language choice matters.
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The New York Times Blogs
(Taking Note)
September 23, 2013 Monday
Sabotaging Health Care
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 488 words
HIGHLIGHT: Wildly misleading ads aim to discourage young people from signing up for health insurance exchanges.
A Koch-brothers funded conservative group, Generation Opportunity, is out with a wildly misleading, pernicious set of ads aimed at sabotaging the Affordable Care Act by discouraging young people from signing up for health insurance exchanges.
One targets young men, the other young women. In the "for him" version, a young man tells his doctor that he saw an ad for the Affordable Care Act and "figured, why not?" The doctor tells him to take his pants off, "hop up here, lay down and bend your knees to your chest." He leaves the room. Then a man wearing an Uncle Sam mask snaps on a blue glove. As if the message weren't perfectly clear, the ad states: "Don't let government play doctor."
The "for her" version is much the same, except in that case Uncle Sam's performing a gynecological exam.
The ads are as offensive as they are derivative.
During the 2012 campaign, the reproductive rights site Lady Parts Justice released a web video attacking laws requiring women to undergo medically unnecessary ultrasounds before receiving abortions. In that spot, a woman with her feet in stirrups explains that she wants an abortion because she's "just not emotionally or financially ready to have kids right now." The doctor, sitting between her legs, responds, "OK, well, just so you know, the law says that before I can do that, I need to do some things to you that you need to pay extra for. You know, just some things that will help you better understand what it is you really want." These "things" include inserting a camera into her vagina and looking at pictures of what's inside her uterus.
But that video made sense-states actually did pass laws interfering with the doctor-patient relationship-whereas the Generation Opportunity ads perpetuate outright lies. Young people who sign up for exchanges won't be getting access to government-run healthcare (if only they were!), but to privately run insurance. Nor does the A.C.A. force doctors to ask patients about their sex lives or perform unwanted exams-as Politifact explained recently. Under the A.C.A., government doesn't "play doctor," it merely enables access to doctors who then decide, using their professional judgment, the best course of action.
Signing up for an exchange isn't an act of political (or sexual) submission. It's just a way to get insurance if you don't have a job or your employer doesn't provide it. The Generation Opportunity crowd surely knows that and obviously doesn't care because its priority now, as ever, is bringing down President Obama's signature domestic accomplishment. The group also doesn't care about the possibility that some number of young people, scared by its ads, will forgo access to affordable care, get sick, and go bankrupt paying their medical bills.
Creepy Uncle Sam Is Back, With More Bad Advice
No Health Insurance? Just Drink.
The Koch Brothers' Advertising Campaign
For Selfish Seniors Only
Shooting at Laws in Ads (Literally)
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The New York Times
June 28, 2015 Sunday
Late Edition - Final
John Roberts, the Umpire in Chief
BYLINE: By JEFFREY ROSEN.
Jeffrey Rosen is the president and chief executive of the National Constitution Center.
SECTION: Section SR; Column 0; Sunday Review Desk; OPINION; Pg. 4
LENGTH: 1356 words
LIBERALS and conservatives were exercised and confused by the combination of Chief Justice John G. Roberts Jr.'s vote to uphold the Affordable Care Act's tax subsidies on Thursday and his dissent from the Supreme Court's decision recognizing a constitutional right of same-sex marriage on Friday. Both sides accused him of voting politically: On Thursday he was taken to task by the right, and on Friday by the left.
In fact, the chief justice's votes in both cases were entirely consistent and constitutionally principled. He embraced a bipartisan vision of judicial restraint based on the idea that the Supreme Court should generally defer to the choices of Congress and state legislatures. His insistence that the court should hesitate to second-guess the political branches regardless of whether liberals or conservatives win is based on his conception of the limited institutional role of the court in relation to the president, Congress and the states.
On Thursday, when Chief Justice Roberts wrote a 6-to-3 decision preserving a key part of the Affordable Care Act (for the second time), Justice Antonin Scalia accused him once again of engaging in liberal judicial activism. ''The somersaults of statutory interpretation'' the chief justice had performed in both health care cases, Justice Scalia wrote, signaled to America ''the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites.''
The Roberts-Scalia debate is part of a longstanding argument about how judges should interpret laws passed by Congress. As Chief Judge Robert A. Katzmann of the United States Court of Appeals for the Second Circuit in New York argues in his recent book, ''Judging Statutes,'' the chief justice embraces an approach called ''purposivism,'' while Justice Scalia prefers ''textualism.'' In Judge Katzmann's account, purposivism has been the approach favored for most of American history by conservative and liberal judges, senators, and representatives, as well as administrative agencies. Purposivism holds that judges shouldn't confine themselves to the words of a law but should try to discern Congress's broader purposes.
In the 1980s, when he was a lower court judge, Justice Scalia began to champion a competing view of statutory interpretation, textualism, which holds that judges should confine themselves to interpreting the words that Congress chose without trying to discern Congress's broader purposes. (By contrast, originalism, which Justice Scalia also embraces, holds that judges should consult both text and history to understand constitutional meaning.) Textualism, in this view, promises to constrain judicial activism by preventing judges from roving through legislative history in search of evidence that supports their own policy preferences. But in the view of its critics, like Chief Judge Katzmann, textualism ''increases the probability that a judge will construe a law in a manner that the legislators did not intend.'' Chief Judge Katzmann, who was appointed by President Bill Clinton, also accuses Justice Scalia of inconsistency for consulting the intent of the framers in the case of constitutional interpretation but not statutory interpretation.
Chief Justice Roberts echoed these criticisms of textualism in his decision holding that federally created health exchanges were eligible for tax subsidies. ''Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,'' the chief justice wrote, in a line that enraged conservatives. ''If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.''
The chief justice's embrace of bipartisan judicial restraint in the second Affordable Care Act case was consistent with his embrace of the same philosophy in the first Affordable Care Act case in 2012, where he quoted one of his heroes, Justice Oliver Wendell Holmes Jr: ''The rule is settled that as between two possible interpretations of a statute, by one of which it would be unconstitutional and by the other valid, our plain duty is to adopt that which will save the Act.''
By construing the Affordable Care Act, twice, in ways that respect Congress's broader purposes rather than thwarting them, Chief Justice Roberts was not, as Justice Scalia charged, rewriting the law. Instead he was advancing the view that he championed soon after his confirmation: In a polarized age, it is important for the Supreme Court to maintain its institutional legitimacy by deferring to the political branches.
The chief justice's dissent on Friday from the court's 5-to-4 decision recognizing a right of same-sex marriage defended precisely the same vision. Once again, he quoted Justice Holmes for the same proposition that he invoked in the Affordable Care Act cases: ''As this Court has been reminded throughout our history, the Constitution 'is made for people of fundamentally differing views.' ''
His dissent in the marriage equality case is undoubtedly the fieriest opinion the chief justice has written on the court. ''Five lawyers have closed the debate and enacted their own vision of marriage,'' he writes. He compares Justice Anthony M. Kennedy's same-sex marriage opinion to Roe v. Wade and to Lochner v. New York, a 1905 case striking down maximum hour laws for bakers, both of which he considers prime examples of judicial activism.
CHIEF JUSTICE ROBERTS insists that his passionate opposition to Justice Kennedy's majority opinion is based on his commitment to judicial restraint, not on his personal disagreement with same-sex marriage. In his dissent on Friday, the chief justice said he would not ''begrudge'' the celebrations that would follow. Instead, his passions were engaged by his commitment to the court's limited role in American politics.
However, the chief justice's commitment to judicial restraint and a limited conception of the court's institutional role is not unvarying. He has written or joined opinions striking down federal campaign finance laws and voting rights laws. Earlier last week, he wrote an opinion for the court that removes one of the last New Deal farm programs propping up price supports for raisins as a violation of the Fifth Amendments prohibition on takings of property without just compensation. In all of these cases, however, Chief Justice Roberts identified a particular clause of the Constitution -- the First Amendment, the Fifth Amendment or the 14th Amendment -- that he believed invalidated the federal law in question. In the marriage equality case, he concluded that no clause of the Constitution clearly protected a right of marriage equality, which is why he accused the majority of substituting its own policy preferences for those of the people, as reflected in state legislation.
It's understandable that liberals and conservatives are disappointed with the chief justice for rejecting positions they deeply favor. But Chief Justice Roberts's relatively consistent embrace of judicial deference to democratic decisions supports his statement during his confirmation hearings that judges should be like umpires calling ''balls and strikes.'' As he put it then: ''Umpires don't make the rules, they apply them. The role of an umpire and a judge is critical. They make sure everybody plays by the rules, but it is a limited role. Nobody ever went to a ballgame to see the umpire.''
Although the chief justice's statement was subsequently mocked, both the Affordable Care Act cases and the marriage equality case show that he meant what he said. Whether writing for the majority or in dissent, he believes that judges should set aside their policy views and generally uphold laws unless they clash with clear prohibitions in the Constitution. In the long term, if he continues to pursue this conception of the deferential role of the court, he may help liberals and conservatives more readily accept their Supreme Court defeats.
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URL: http://www.nytimes.com/2015/06/28/opinion/john-roberts-the-umpire-in-chief.html
LOAD-DATE: June 28, 2015
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The New York Times Blogs
(The Learning Network)
October 8, 2013 Tuesday
Beyond the Rhetoric: Researching and Writing About the Health Care Law
BYLINE: TOM MARSHALL and MICHAEL GONCHAR
SECTION: EDUCATION
LENGTH: 1529 words
HIGHLIGHT: In this lesson, students will research the fundamentals of the largest national health insurance expansion in generations. Then they will design a brochure to answer important questions about the program and its relevance for their community, as well as the nation.
Overview | What is the Affordable Care Act, otherwise known as Obamacare, and why do some consider it a solution to the national health care crisis, while others see it as a dangerous expansion of the federal government? In this lesson, students will learn about the largest national health insurance expansion in generations through conducting community interviews, then researching answers to frequently-asked questions. Then they will design a brochure or presentation to address questions about the program and its relevance for their communities.
Materials | Computer with Internet connection and projector to display articles and multimedia; computers with Internet connection for individual students or groups to use online resources, or copies of stories and related documents as needed.
Warm-Up | Tap into students' prior knowledge and opinions about the law, which most students will probably have heard of but that may be confused about. Students can answer the following three questions in their notebooks:
What facts do you know (or think you know) about the Affordable Care Act?
Do you support or oppose the law? Why?
What questions do you have about it? What don't you understand?
As students share answers, write down their questions on the board. These can be useful later in the activity when students are generating research questions.
Related | In the article "Millions of Poor Are Left Uncovered by Health Law," Sabrina Tavernise and Robert Gebeloff report on the wide disparity in how the Affordable Care Act is being implemented across the states. Have students read the article with a pen in hand, circling any statement either in support of or against the law.
A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.
Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. ...
"How can somebody in poverty not be eligible for subsidies?" an unemployed health care worker in Virginia asked through tears. The woman, who identified herself only as Robin L. because she does not want potential employers to know she is down on her luck, thought she had run into a computer problem when she went online Tuesday and learned she would not qualify."
Read the entire article with your class. You may wish to introduce students to the following words or concepts before reading: subsidies, disproportionate, exclusion, demographics, onerous, and predominantly.
Questions | For reading comprehension and discussion:
Why are some people - including African-Americans, single women and low-income workers - still ineligible for health care, even though the new law was trying to get it for them?
Why have some states refused to expand Medicaid? What reasons do they give?
Does race or politics seem to have anything to do with this discussion? Explain.
This story mentions two doctors and two state senators who work in Mississippi. How does each person feel about the health care law and the expansion of Medicaid? What is your evidence?
Activity | Note: On Oct. 1 the centerpiece of the Affordable Care Act, state and national health insurance exchanges, opened for business. At the same time, the government experienced its first shutdown in 17 years after House Republicans tied the federal budget to defunding or delaying the health care law. We see this national debate as an ideal opportunity for students to practice reading and using the kinds of informational texts that have a real impact on their lives and the lives of those in their families and communities.
The activity is structured as a research project that culminates in students designing an FAQ brochure (or PowerPoint, Prezi or other presentation media). The FAQ ("Frequently Asked Questions") format should give students the flexibility to address the questions they think are most useful and relevant. Here are the steps:
Step 1: Conduct Interviews | Students can work as individuals, pairs or small groups. They should interview adults in their community (teachers, family members or neighbors), asking the following questions about the health care law:
Do you support or oppose the health care law? Why?
What questions do you have about it?
Step 2: Develop Questions | Next, students should generate a list of questions they want to research about the health care law. They can start by borrowing questions from the class Warm Up activity, from their interview results and from our list of "Questions to Consider" below.
Step 3: Conduct Research | Students should find trustworthy sources that address their questions. We have listed a few below in different categories to get you started, from The Times and elsewhere. Students should be cautioned to distinguish between journalistic reporting and opinion pieces, and they should be sure to cite their sources.
Step 4: Create Brochure | When ready, students should design their brochure, PowerPoint, Prezi or other presentation medium. The FAQ should present questions and answers in a logical order.
Step 5: Revise and Edit | The health care law is a lightning-rod issue right now, so students should take care to ensure their language is objective and their sources reliable.
Step 6: Publish and Present | Students can share their presentations with the class, bring them home to their families, or perhaps even present their findings to the school staff or in a community meeting.
[Video: This Kaiser Family Foundation's animated video explains details of health care reform. Watch on YouTube.]
Questions to Consider
What is the health care law, and what does is intend to accomplish?
Everything You Need to Know About Life Under Obamacare - Washington Post primer on the health care law
A History of Overhauling Health Care - interactive timelines
What are the health exchanges that opened on Oct. 1?
Early Interest for Online Health Markets - video about opening day for exchanges
Opening Rush to Insurance Markets Runs Into Snags - article about Day 1 of the exchanges
As Demand Stays High, Officials Try to Address Problems in Exchanges - article about Day 2
Does the law succeed in providing affordable health care to the previously uninsured?
'Affordable Care' or a Rip-Off? - news analysis piece
On the Threshold of Obamacare, Warily - vignettes about real people shopping for health insurance
Why are many people opposed to the health care law? Why are House Republicans trying to repeal it? How might this law be bad for the United States?
Uninsured Americans Divided on Impact of Health Care Law - poll results
U.S. Employers Slashing Worker Hours to Avoid Obamacare Insurance Mandate - article in The Guardian
Despite Criticisms, Health Care Law's Impact on Jobs Is Still Unclear - article about economic impact of the health care law
Is Obamacare Working? - Room for Debate panel on health care law
Obamacare Is the Right's Worst Nightmare - Opinion piece
Five Reasons Americans Already Love Obamacare - Plus One Reason Why They're Gonna Love It Even More, Soon - Opinion piece on Fox News
POLL: More oppose 'Obamacare' than 'Affordable Care Act' - poll results
Let's Delay 'Obamacare' for a Year, So We Can Kill It - an Opinion piece by two Republican members of Congress in The Arizona Republic
My State Needs Obamacare. Now. - Op-Ed by Kentucky's governor
Common Core ELA Anchor Standards, 6-12
Reading
1. Read closely to determine what the text says explicitly and to make logical inferences from it; cite specific textual evidence when writing or speaking to support conclusions drawn from the text.
2. Determine central ideas or themes of a text and analyze their development; summarize the key supporting details and ideas.
8. Delineate and evaluate the argument and specific claims in a text, including the validity of the reasoning as well as the relevance and sufficiency of the evidence.
Writing
2. Write informative/explanatory texts to examine and convey complex ideas and information clearly and accurately through the effective selection, organization and analysis of content.
8. Gather relevant information from multiple print and digital sources, assess the credibility and accuracy of each source, and integrate the information while avoiding plagiarism.
McREL Standards
Civics
2. Understands the essential characteristics of limited and unlimited governments
3. Understands the sources, purposes, and functions of law, and the importance of the rule of law for the protection of individual rights and the common good
6 Q's About the News | Senate Votes to Move Forward on Budget Debate
6 Q's About the News | Possible U.S. Government Shutdown Looms
Supreme Court Rules on Health Care
Before the Law: Understanding the Supreme Court Case on the Affordable Care Act
What Is Your Reaction to the Rush Limbaugh Controversy?
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The New York Times Blogs
(Bill Keller)
July 18, 2012 Wednesday
More Myths of Obamacare
BYLINE: BILL KELLER
SECTION: OPINION
LENGTH: 1051 words
HIGHLIGHT: An expanded list of fallacies about the Affordable Care Act.
If only I'd checked with you first, Times readers, I could have expanded my list of fallacies about the Affordable Care Act. Thanks to your comments and emails on my column,I've noted a few more enduring myths that seem worthy of debunking. See below.
But first, let me field a bit of incoming flak.
An astute reader took issue with my statement that the law will "deliver 30 million new customers to the insurance industry." In fact, some of those 30 million will be poor enough to qualify for Medicaid, and will not end up in the private market. How many? Because the same Supreme Court case that approved the mandate also allowed states to opt out of expanded Medicaid, it's impossible to say. Estimates were that if the states had to participate, roughly half of the 30 million would qualify for Medicaid, but under the Supreme Court ruling the number is likely to be far fewer. (We're publishing a correction on the 30 million.) But my point stands that the law, although it imposes new rules on insurers, is not a "federal takeover" of health insurance. For better or worse, it preserves our private insurance industry and requires that millions of additional customers buy their products.
On the "job-killer" front, I heard from a number of small businessmen who insisted the new law would prevent them from hiring more workers if it increased their payroll to more than 50 employees. Under Obamacare, companies with more than 50 workers are obliged to provide health insurance or pay an annual fine of $2,000 per excess worker beyond the first 30-roughly a dollar per hour for a full-time employee. I appreciate the visceral reluctance to take on additional costs and paperwork, and can imagine marginal cases where a small company would decide it's not worthwhile to grow. But I'm skeptical that many savvy businessmen would turn down a good opportunity to expand simply to avoid offering workers health insurance. If the value of the new business is greater than the employer's share of an insurance plan or a fine, you go for it, right? That's called capitalism.
Two other reasons the arguments that Obamacare is a job-killer don't add up:
1. Although small-business lobbies tend not to mention it, businesses with fewer than 25 employees that already offer health insurance will be eligible for new tax credits; that will free up money for investment.
2. The increased access to health care will create new jobs in the health care industry itself. As Harvard health economistKatherine Baicker has cautioned,expanding the health care sector should not be a goal of reform; it's more important to get the existing system working more efficiently. But providing access to systematic primary care for 30 million newcomers is bound to create new demand, not just for doctors and nurses but (as Jonathan Gruber of MIT has written) for assistants and technicians and support staff - "precisely the sort of medium-skill jobs that our economy desperately needs."
For these and other reasons, most economists who have studied the likely impact on employment say it will be quite small.
There is considerable-and healthy-doubt about how well the Affordable Care Act will accomplish its second major aim, aside from expanding coverage: slowing the raging growth of health care spending. I agree that it will require real vigilance and oversight, and probably some fixes to the law, if Obamacare is to, as the saying goes, "bend the cost curve" downward. It will require moving more doctors from fee-per-service to salaries, more collaborative care, better electronic sharing of patient information, better controls on in-hospital infections. (Reforms of medical malpractice law, an issue Obamacare skirted, would help, too.) The Affordable Care Act takes first steps towards controlling the costs of our bloated system, but they are only first steps.
Now, the myths, continued.
Myth #6: Unions that supported Obama don't have to comply with Obamacare. This allegation, repeated by several readers, harkens back to an anti-Obamacare ad by a Republican campaign group. The website PolitiFact skewered it last year. Briefly, one important provision of the new law forbids insurers from putting a cap of less than $750,000 on the care a person can get in one year. Some companies argued that if they complied right away, they would have to raise premiums on their workers or stop offering insurance altogether. To prevent that, the Obama administration government has granted waivers to companies (and unions) allowing them to keep the more limited insurance plans in place until 2014. Politifact said the waivers have been granted to both companies and unions, with no pattern of special treatment.
Myth #7: Obamacare creates a secretive board of bureaucrats with power to cut off grandpa's dialysis or grandma's chemotherapy. You don't hear the phrase "death panels" much any more, but variations of that fallacy persist, like sightings of Sasquatch. The new law establishes an Independent Payment Advisory Board of health care professionals to propose ways to curb the growth of Medicare spending. It operates in public and makes systemic recommendations, which Congress can overrule. The board can reduce the amount Medicare pays health care providers for services and propose innovations to cut waste. It has no say in the treatment of any individual; it cannot change eligibility for Medicare, reduce benefits or raise premiums.
Myth #8: Obamacare is a distraction from the main issue, which is jobs. This is the flip side of Myth #1, that Obamacare is a job-killer. You hear critics, right and left, saying that Obama took his eye off the ball-the economy-when he set out to push the health care act through Congress. TV anchors are constantly showing us polling results in which voters identify issues that matter most to them, with health care ranking a distant second or third to "the economy" or "jobs." The implication is that health insurance is a side issue, unworthy of so much attention. But health insurance is inseparable from the larger discussion, both as a matter of economics and as a matter of psychology. Containing the cost of health care is integral to the fate of our economy. And the current dependency on employers for health insurance contributes mightily to the fear of losing a job.
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The New York Times Blogs
(Taking Note)
October 24, 2013 Thursday
G.O.P. Roots for Failure
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 600 words
HIGHLIGHT: Republicans have done everything in their power to dismantle the Affordable Care Act. It’s understandable that Democrats question their motives.
In theory, lawmakers hope that government programs work well, and if they don't, try to fix them. In theory, our representatives hope that government agencies carry out their missions smoothly, and if something goes wrong, try to figure out what happened to avoid making the same mistake in the future.
Obviously that's not how things work in the United States, where one of the two parties doesn't even believe in government. Republicans want to shrink government until it's small enough to drown in a bathtub! They think there's nothing scarier than the prospect of a government employee trying to help! With beliefs like those, it's not surprising that - with disturbing frequency - they root for failure in order to score points.
Examples abound. After the attack in Benghazi, G.O.P. lawmakers were far more interested in laying blame and making the Obama administration look bad than in improving security for diplomats. In the midst of the I.R.S. scandal - which turned out not to be much of a scandal at all - Republicans seemed positively gleeful.
Which brings us to today's House hearing on the bumpy rollout of the federal health insurance marketplace.
The rollout is bumpy, and inexcusably so. It appears that the federal exchange Web site wasn't fully tested until two weeks before it opened. As today's Times story put it, the online health insurance marketplace "is still limping along after three weeks."
Lawmakers can and should hold the administration to account. But given that House Republicans have done everything in their power to try to dismantle the Affordable Care Act - including shutting down the entire government - it's understandable that House Democrats expressed suspicion about their motives.
"I wish I could believe that this hearing is above board, but it's not," said Representative Frank Pallone, Democrat of New Jersey. "The Republicans don't have clean hands coming here. Their effort is obviously not to make this better, but to use the website glitches as an excuse to defund or repeal Obamacare."
Taking the same line, Representative Henry Waxman, Democrat of California, said: "We have already documented a record of Republicans attempting to sabotage the Affordable Care Act." He added, "If we want this law to work, we have to make this right; we've got to fix it. Not what the Republicans are trying to do: nix it and repeal it."
Although some Republicans asked valid and thoughtful questions of the private contractors who'd come to testify, others seemed to prove Mr. Pallone and Mr. Waxman right.
Representative Joe Pitts, Republican of Pennsylvania, took the opportunity to say he would seek a delay in the individual mandate-exactly what Republicans wanted before there was any word of trouble with the online exchanges. Healthcare.gov is "nothing less than an unmitigated disaster," Mr. Pitts said. He also wondered aloud if the people behind it were "simply incompetent" or else "lying to the American people."
"If the Web site glitches are just the tip of the iceberg," said Representative Greg Walden, Republican of Oregon, "it's only a matter of time before the law sinks and takes with it those Democrats who wrote it, voted for it and are proud of it."
Breaking that down: If the glitches indicate deep problems, then health care reform will fall apart, in which case Republicans will pick up seats in the next election. In other words, disaster would be good for his party.
Some Republicans Change Course on Health Care
Is the Health Care Fight Over?
Boehner's Last Stand
G.O.P. Helps Americans Like Government
A New Danger for Democrats: Boehner's Delegation
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The New York Times
February 8, 2017 Wednesday
Late Edition - Final
Many Don't Know Obamacare and Affordable Care Act Are the Same
BYLINE: By KYLE DROPP and BRENDAN NYHAN; .
SECTION: Section A; Column 0; National Desk; SURVEY SAYS; Pg. 10
LENGTH: 566 words
A sizable minority of Americans don't understand that Obamacare is just another name for the Affordable Care Act.
This finding, from a poll by Morning Consult, illustrates the extent of public confusion over a health law that President Trump and Republicans in Congress hope to repeal.
In the survey, 35 percent of respondents said either they thought Obamacare and the Affordable Care Act were different policies (17 percent) or didn't know if they were the same or different (18 percent). This confusion was more pronounced among people 18 to 29 and those who earn less than $50,000 -- two groups that could be significantly affected by repeal.
Among Republicans, a higher percentage (72 percent) said they knew Obamacare and the A.C.A. were the same, which may reflect the party's longstanding hostility to the law.
When respondents were asked what would happen if Obamacare were repealed, even more people were stumped. Approximately 45 percent did not know that the A.C.A. would be repealed. Twelve percent of Americans said the A.C.A. would not be repealed, and 32 percent said they didn't know.
Confusion about the health law has been persistent. Several years ago, the late-night host Jimmy Kimmel poked fun at people who thought Obamacare and the A.C.A. were different, and similar examples spread on social media last month after Congress paved the way for repeal. (Republicans say they will replace the law with a better policy but have not agreed on any legislation.)
This confusion may affect the public debate over health care policy. If many people think repealing Obamacare would not affect the popular provisions of the A.C.A., they might not understand the potential consequences of the proposals being considered in Washington.
For instance, only 61 percent of adults knew that many people would lose coverage through Medicaid or subsidies for private health insurance if the A.C.A. were repealed and no replacement enacted. In contrast, approximately one in six Americans, or 16 percent, said that ''coverage through Medicaid and subsidies that help people buy private health insurance would not be affected'' by repeal, and 23 percent did not know.
Knowledge of the policy consequences of repeal without replacement differed especially sharply along partisan lines. Though Republicans were more likely to know that Obamacare is another name for the A.C.A., only 47 percent of them said expanded Medicaid coverage and private insurance subsidies would be eliminated under repeal (compared with 79 percent of Democrats), while 29 percent said Medicaid and subsidies would not be affected and 24 percent said they didn't know.
Despite this widespread confusion, Republicans in Congress have recently started to edge away from A.C.A. repeal as the politics of the issue have become more difficult. What would happen if people understood the law better?
The survey was conducted by Morning Consult on Jan. 25 and 26 among a national sample of 1,890 adults. Interviews were conducted online, and the data were weighted to approximate a target sample of adults based on age, race/ethnicity, gender, educational attainment and region. Results from the full survey have a margin of error of plus or minus 2 percentage points.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.
URL: http://www.nytimes.com/2017/02/07/upshot/one-third-dont-know-obamacare-and-affordable-care-act-are-the-same.html
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The New York Times
February 16, 2017 Thursday
Late Edition - Final
Repair Then Repeal: Trump's Health Market Plan
BYLINE: By ROBERT PEAR; Thomas Kaplan and Margot Sanger-Katz contributed reporting from Washington, and Reed Abelson from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1272 words
WASHINGTON -- The Trump administration proposed new rules on Wednesday to stabilize health insurance markets roiled by efforts to repeal the Affordable Care Act, by big increases in premiums and by the exodus of major insurers.
The move came a day after Humana announced that, starting next year, it would completely withdraw from the public marketplaces created by former President Barack Obama's signature domestic achievement.
The proposed rules, backed by insurance companies, would tighten certain enrollment procedures and cut the health law's open enrollment period in half, in hopes that a smaller but healthier consumer base will put the marketplaces on sounder financial footing and attract more insurance companies in states with limited choices.
But part of the market's problem stems from President Trump's determination to repeal the health law while the White House and Congress struggle to find a politically acceptable replacement. Even as the Department of Health and Human Services worked to answer insurance company concerns, the Internal Revenue Service and Congress were taking steps that could add uncertainty to the jittery insurance economy.
On Capitol Hill, conservatives declared that they are not about to accept a health law replacement that remotely resembles the Affordable Care Act. And the I.R.S. adopted a policy for the coming tax season that could weaken the requirement for people to have insurance. The tax agency said it was reversing one aspect of an Obama administration plan after Mr. Trump, on his first day in office, issued an executive order instructing agencies to reduce burdens imposed by compliance with the Affordable Care Act wherever legally possible.
The proposed rules signal the Trump administration's urgency in trying to keep other insurers from fleeing the market after Humana's departure. The company said on Tuesday that it was losing money by insuring too many sick people without enough healthy ones enrolling. Humana had already scaled back its participation to 11 states this year, from 19 in 2016.
Mark T. Bertolini, the chief executive of Aetna, said Wednesday that the marketplaces were in ''a death spiral,'' and at a conference sponsored by The Wall Street Journal, he declined to say if his company would participate next year. And Molina Healthcare, one of the few insurers that seemed to be financially successful under the health law, reported on Wednesday that it was losing money in the marketplaces. It threatened to drop out if its concerns about a risk-sharing program requiring the company to pay hundreds of millions of dollars to other insurers were not addressed.
Dr. Patrick H. Conway, the acting administrator of the Centers for Medicare and Medicaid Services, said the rules proposed on Wednesday ''will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.''
But Democrats and consumer groups denounced the proposed rules, saying they would make it more difficult for people to enroll and increase costs for some consumers.
Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, said the rules sent ''a clear message to the American people: Patients are not a priority, and insurance companies are back in charge.''
Under the proposed rules, the annual open enrollment period would be reduced to about six weeks from two months. The shorter time frame would be similar to the open enrollment periods for Medicare and for many employer-sponsored health plans.
But the administration acknowledged that the shorter sign-up period ''could lead to a reduction in enrollees, primarily younger and healthier enrollees'' who often sign up near the deadline.
Other parts of the rules would limit opportunities for people to hold off on buying insurance until they get sick, a phenomenon that has loaded many health plans offered under the Affordable Care Act with more expensive, sick customers than they expected. By manipulating a system that now precludes insurers from rejecting customers with pre-existing medical conditions, consumers are avoiding the purchase of insurance when they are healthy and rushing in when they need it, insurers say.
The rules also would require consumers to provide ''supporting documentation'' to prove they were eligible to enroll in health plans through HealthCare.gov outside the standard open enrollment season. The administration estimated that 650,000 people annually could have their enrollment delayed because of the new requirement to verify eligibility.
People can sign up after the deadline if they experience certain ''life changes'' like having a baby, getting married or losing employer-sponsored insurance. Insurers have told the government for several years that people who sign up in a special enrollment period use up to 50 percent more services than those who sign up in the regular enrollment season.
Insurers and Republican members of Congress welcomed the proposed changes, which will be published in the Federal Register on Friday, giving the public until March 7 to comment. Final rules are likely to be issued in March or April. Insurers must decide by early May what kinds of health plans they will offer in 2018.
Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said the proposals were ''important first steps to rescue a collapsing Obamacare individual market.''
But insurers cautioned that the proposed rules, while helpful, would in no way provide a solution if, in a few weeks, Republicans introduce legislation to repeal major provisions of the Affordable Care Act, such as the requirement for most Americans to have coverage.
Christopher W. Hansen, the president of the advocacy arm of the American Cancer Society, said the tighter restrictions on special enrollment periods could ''cause problems for cancer patients,'' delaying treatment and reducing their chances of survival.
Changes being made by the I.R.S. could weaken incentives for people to obtain insurance. The tax agency said it would accept and process tax returns even if taxpayers failed to indicate whether they had coverage, qualified for an exemption or were paying the penalty for going without insurance.
The individual mandate, requiring most Americans to have insurance, was to be enforced through the tax system. The I.R.S. said the requirement was ''still in force until changed by Congress.'' The government can deduct the amount of any penalty from refunds that would otherwise be sent to taxpayers. But it is unclear how it will use this authority.
In the rules proposed Wednesday, the Trump administration said that it would generally allow states to determine whether insurance plans had enough doctors, hospitals and other health care providers to serve patients. The hope is that would lure more insurers into the market. Additionally, insurers could refuse to provide new coverage to consumers who failed to pay premiums owed in the previous year. If an insurer terminates coverage for nonpayment of premiums, it could require consumers to pay all past-due premiums owed to that insurer before restarting coverage.
And insurers would be allowed to sell health plans covering a smaller share of expected costs. The administration said consumers would have ''more coverage options'' as a result, but it acknowledged that some consumers could see increases in their deductibles and other out-of-pocket costs.
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URL: http://www.nytimes.com/2017/02/15/us/politics/affordable-care-act-obamacare-trump.html
LOAD-DATE: February 16, 2017
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: A consumer signed up for health insurance on Jan. 31, the final day of open enrollment this year under the Affordable Care Act. (PHOTOGRAPH BY LYNNE SLADKY/ASSOCIATED PRESS) (A13)
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The New York Times
March 4, 2016 Friday
Late Edition - Final
Affordable Care Act Reaches a Milestone
BYLINE: By GARDINER HARRIS; Robert Pear contributed reporting from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 756 words
MILWAUKEE -- President Obama said on Thursday that enrollment in health coverage under the Affordable Care Act had reached a new high, 20 million, and he called the law an overwhelming success in this city and around the nation despite Republicans' implacable opposition.
''Congressional Republicans have tried and failed to repeal Obamacare about 60 times,'' Mr. Obama said to an audience here. ''They have told you what they would replace it with about zero times.''
He continued, his voice rising: ''If they got their way, 20 million people would have their insurance taken away from them. Twenty million people!''
The 20 million figure includes people who have received private health insurance on exchanges, those who gained Medicaid coverage under state expansions and young adults who were able to stay on their parents' health plans until age 26, the administration said.
In its last comparable estimate, in September, the administration said 17.6 million uninsured people had gained coverage.
Mr. Obama's trip was intended to reward Milwaukee, which won a nationwide competition called Healthy Communities by enrolling an estimated 38,376 people in private health insurance under the health care law. That was about 75 percent of previously uninsured residents who were eligible, a rate higher than that of any other city.
The law has been particularly successful in places like Milwaukee, where a coalition of local leaders, charities and health care companies have worked to sign up those who did not have health insurance.
Average insurance premiums in the city fell 2.1 percent for 2016 plans, according to the Kaiser Family Foundation. ''It's an example of what community outreach can do even in the face of a governor who is not supportive of the A.C.A.,'' said Drew Altman, the president and chief executive of the foundation, which focuses on health issues.
Wisconsin's Republican governor, Scott Walker, who has disparaged the health law, expanded the state's Medicaid program just short of the level that would allow the state to receive hundreds of millions of dollars in federal aid.
Mr. Walker has argued that federal funding is uncertain over the long term. ''If anyone thinks the federal government, which is currently $18 trillion in debt, will not renege on its future funding promises, they are not living in reality,'' Laurel Patrick, the governor's press secretary, said in an email.
But no state would save more money by further expanding Medicaid than Wisconsin, according to an estimate by the Wisconsin Council on Children and Families, a nonprofit group.
''Your governor still refuses to expand Medicaid, which, by the way, actually would save money,'' Mr. Obama said. ''He's denying Wisconsinites their ticket to health insurance, and it's political.''
The Milwaukee county executive, Chris Abele, a Democrat, said in a speech on Thursday that city leaders were pleased to win the Health Communities contest, but that it was not the motivation for their efforts.
''We did it because thousands of people in this county who never had health care before do now,'' Mr. Abele said. ''We also did it because the Affordable Care Act has already saved -- I wrote that in big, bold letters -- saved the county over $2 million.''
Before Mr. Obama's address at a middle school, he stopped at a restaurant, Engine Company 3, to speak to a handful of people who had written letters to him about the law. Among them was Brent Brown, of Mosinee, Wis., a Republican who later introduced the president to a raucous crowd of about 700 at the school.
''To be clear, I have never voted for President Obama,'' he said. ''Ever.''
Mr. Brown said that the health law had saved his life after he became desperately ill.
''And to the Republicans who wish to repeal the Affordable Care Act, I plead with you to reconsider,'' Mr. Brown said. ''Swallow your pride -- as I am doing right now in front of many Democrats -- and do what is right.''
Mr. Obama said that as many as 129 million Americans with pre-existing conditions could no longer be charged more or denied coverage because of that prior illness, and that 140 million Americans now got free preventive care such as mammograms.
''So your insurance is better than it was even if you don't know it, even if you didn't vote for me. Thanks, Obama,'' the president said to a roar of laughter. ''You got an upgrade.''
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URL: http://www.nytimes.com/2016/03/04/us/politics/obama-heads-to-wisconsin-to-promote-successes-of-affordable-care-act.html
LOAD-DATE: March 4, 2016
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: President Obama on Thursday in Milwaukee, which won a competition for enrolling 38,376 people in health insurance plans. (PHOTOGRAPH BY ZACH GIBSON/THE NEW YORK TIMES)
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(Taking Note)
September 26, 2014 Friday
How Medicaid Expansion Helps Hospitals
BYLINE: PHILIP M. BOFFEY
SECTION: OPINION
LENGTH: 200 words
HIGHLIGHT: Recalcitrant states are depriving their local hospitals of substantial savings.
Governors and legislative leaders in the (mostly red) states that have refused to expand their Medicaid programs have another good reason to regret their choice.
Under the Affordable Care Act, the government pays 100 percent of the cost of covering newly eligible enrollees through 2016 after which it tapers down to 90 percent of the costs in 2020 and subsequent years. It was always clear that lawmakers who turned their backs on that offer would harm their low-income residents.Now the Department of Health and Human Services has issued a report showing that recalcitrant states will harm the hospitals that serve poor people as well. The report indicates that, thanks to the Affordable Care Act, hospitals across the country will save $5.7 billion in uncompensated care costs in 2014 because patients who previously failed to pay their bills will now be covered by expanded Medicaid programs or by other insurance plans.
Projections suggest that $4.2 billion of the total savings will come from Medicaid expansion states. Thus far 27 states and the District of Columbia have expanded Medicaid but 23 states have not. Those 23 are depriving their local hospitals, collectively, of substantial savings.
LOAD-DATE: September 26, 2014
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July 3, 2015 Friday
The New York Times on the Web
Supreme Court Ruling on Health Care Bolsters Deal-Making
BYLINE: By ROBERT CYRAN
SECTION: Section ; Column 0; Dealbook; BREAKINGVIEWS; Pg.
LENGTH: 302 words
Health care deal-making is ramping up after a booster shot from the Affordable Care Act. The Supreme Court's decision last week to uphold President Obama's landmark reform signaled the official start of a race to consolidate. Centene's $6.3 billion purchase of Health Net gives the insurers an early lead, but bigger rivals like Cigna and Anthem may soon catch up.
The latest deal could deliver substantial benefits. Centene is claiming $150 million in potential savings, and their value, taxed and capitalized on a multiple of 10, roughly equals the price's premium.
The Affordable Care Act offers even more possible benefits. More than 16 million Americans have obtained insurance coverage because of President Obama's law, many as a result of its expansion of Medicaid. The program for low-income people is the focus of Centene's and Health Net's businesses. And with more than 10 percent of the American public still lacking insurance, there's plenty of room for growth -- especially in California, Health Net's home base.
The challenge is to act quickly. Medicaid is stingy with payments, and the health law has provisions that could limit profit margins for insurers involved with the program while requiring better care from providers. That has prompted hospitals and insurers to haggle fiercely over patient dollars. The companies that can get bigger sooner gain negotiating heft.
It's no wonder the five largest health insurers are sniffing around one another. Cigna and Aetna are potential buyers as well as acquisition targets. Centene may have got an early jump on those giants. Now that it is understood the law is here to stay, though, other deals should follow quickly.
Robert Cyran is a columnist for Reuters Breakingviews. For more independent commentary and analysis, visit breakingviews.com.
URL: http://www.nytimes.com/2015/07/03/business/dealbook/supreme-court-ruling-on-health-care-bolsters-deal-making.html
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The New York Times
November 15, 2014 Saturday
Late Edition - Final
Cost of Coverage Under Care Act Set to Increase
BYLINE: By ROBERT PEAR, REED ABELSON and AGUSTIN ARMENDARIZ
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 961 words
WASHINGTON -- The Obama administration on Friday unveiled data showing that many Americans with health insurance bought under the Affordable Care Act could face substantial price increases next year -- in some cases as much as 20 percent -- unless they switch plans.
The data became available just hours before the health insurance marketplace was to open to buyers seeking insurance for 2015.
An analysis of the data by The New York Times suggests that although consumers will often be able to find new health plans with prices comparable to those they now pay, the situation varies greatly from state to state and even among counties in the same state.
''Consumers should shop around,'' said Marilyn B. Tavenner, administrator of the Centers for Medicare and Medicaid Services, which runs the federal insurance exchange serving three dozen states. ''With new options available this year, they're likely to find a better deal.'' She asserted that the data showed that ''the Affordable Care Act is working.''
But Republicans quickly pounced on the data as evidence of the opposite.
''Last year, many who liked their plan were surprised to learn they couldn't keep it,'' said Senator Orrin G. Hatch of Utah, who is in line to become chairman of the Senate Finance Committee. ''This year, many who like their plan will likely have to pay more to keep it.''
The new data means that many of the seven million people who have bought insurance through federal and state exchanges will have to change to different health plans if they want to avoid paying more -- an inconvenience for consumers just becoming accustomed to their coverage.
A new Gallup Poll suggests that seven in 10 Americans with insurance bought through the exchanges rate the coverage and the care as excellent or good, and most were planning to keep it.
In employer-sponsored health plans, employees tend to stay with the same insurer from year to year. But for consumers in the public insurance exchanges, that will often be a mistake, experts said.
Nashville illustrates the need for people with marketplace coverage to look closely at the alternatives available in 2015.
A 40-year-old in Nashville, with the cheapest midlevel, or silver plan, will pay $220 a month next year, compared to $181 a month this year, for the same plan.
The least expensive plan is offered by another insurer, Community Health Alliance, one of the so-called co-op plans created under the federal law. It offers coverage for a monthly premium of $194.
But the lower premium means that consumers will have to pay a much larger annual deductible, $4,000, rather than $2,000. A policyholder who becomes seriously ill or has a costly chronic condition could pay hundreds of dollars in out-of-pocket expenses.
In addition, different health plans often have different networks of doctors and hospitals and cover different drugs, meaning that consumers who change plans may have to pay more for the same medicines.
Another problem for consumers is that if the price for a low-cost benchmark plan in the area has dropped, the amount of federal subsidies provided by the law could be less, meaning that consumers may have to pay more unless they switch plans.
The data, released by the Centers for Medicare and Medicaid Services, indicates that price increases will be modest for many people willing to change plans. In a typical county, the price will rise 5 percent for the cheapest silver plan and 4 percent for the second cheapest.
Experts said the wide swings in prices were likely to continue. ''Next year will see another reshuffling,'' said Caroline F. Pearson, a vice president of Avalere Health, a research and consulting company. ''Eventually, in a year or two, we will start to stabilize.''
The Times analysis found that premiums had increased much more sharply in places where fewer insurers were competing for customers. Prices for the lowest-cost silver plan increased by at least 5 percent in 89 percent of the counties with a single insurer. About a quarter of counties with one or two insurers saw an increase in rates of more than 10 percent. The analysis did not calculate how prices might change for people who keep their plans.
In 2015, as in 2014, large numbers of health plans have high deductibles -- the amount that consumers owe before the insurer starts to pay.
In Muscogee County, Ga., which includes Columbus, 74 health plans are available on the federal exchange. Fifty-two of the plans have deductibles of $2,500 or more, and 27 have deductibles of $5,000 or more.
The Internal Revenue Service defines a high-deductible plan as one with a deductible of $1,300 or more.
In Charleston, W.Va., the state capital, only 14 health plans are available, and all are offered by Highmark Blue Cross and Blue Shield. Half of the plans have deductibles of $2,500 or more, and one has a deductible of $5,000 or more.
In Jeff Davis County in West Texas, 17 plans are available. All but four have deductibles of $2,500 or more, and seven plans have deductibles of $5,000 or more. By contrast, Dallas residents have a choice of 64 plans, and in Houston, 71 are available.
In releasing the data, administration officials noted that more insurers had entered the market in many states. By the government's count, 25 percent more insurers will be participating in the exchange next year, and consumers will have a choice of 40 different plans, on average, up from 31 this year.
New Hampshire shows how consumers may benefit from additional competition. In most of the state, the number of insurers is increasing to five in 2015, from just one this year. Prices for the lowest-cost silver plan have fallen by 14 percent.
But there remain large stretches of the country where consumers will still have a limited number of insurers to choose from.
URL: http://www.nytimes.com/2014/11/15/us/politics/cost-of-coverage-under-affordable-care-act-to-increase-in-2015.html
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GRAPHIC: PHOTO: Marilyn B. Tavenner, administrator of the Centers for Medicare and Medicaid Services, which runs the federal health exchange. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A12) MAPS: Where Health Insurance Rates Will Increase . . .: In about a fifth of the counties in states using the federal insurance exchange, premiums for the lowest-priced silver plans will increase by 10 percent or more.
. . . And Decrease: But rates for the same plans will decrease in all of Maine, Montana and New Hampshire, and most parts of Mississippi and South Dakota. (Source: Centers for Medicare and Medicaid Services) (A12)
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The New York Times
October 18, 2016 Tuesday
Late Edition - Final
HealthCare.gov Will Add 'Simple Choice' Plans in Effort to Improve Value
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 886 words
WASHINGTON -- When the Affordable Care Act's health insurance marketplace opens in two weeks, many consumers will have a new option for the law's fourth open-enrollment period: standardized health plans that cover basic services without a deductible.
With many health plans on the marketplace coming with deductibles in the thousands of dollars, consumers have complained that they were getting little benefit beyond coverage for catastrophic problems. The new standardized options are meant to address that concern -- to ensure that ''enrollees receive some upfront value for their premium dollars,'' as the Obama administration said.
''Too many people, especially people on high-deductible plans, are still struggling to afford the care they need,'' Senator Sherrod Brown, Democrat of Ohio, said, praising the new effort.
But the new plans could still be costly. While the federal government specifies deductibles, co-payments and other out-of-pocket costs for the standardized options, it does not limit premiums, which in most cases are still regulated by state insurance commissioners. The administration has said it does not expect the standardized options to have a significant effect on premiums in 2017.
Federal officials say the new option will simplify shopping under the Affordable Care Act by reducing variation among plans, and consumer advocates like the idea. The standardized options will be identified on HealthCare.gov with the label ''Simple Choice.''
Open enrollment begins Nov. 1 and runs through Jan. 31. People without health insurance next year face possible tax penalties that could exceed $700 a person.
''This is one more tool that will make it easier for consumers to select the right plan,'' said Marjorie K. Connolly, a spokeswoman for the Department of Health and Human Services.
Sandy H. Ahn, a researcher at the Health Policy Institute of Georgetown University, said the ''standardized plans will allow consumers to make more of an apples-to-apples comparison.''
Administration officials did not say how many such plans will be available, in which states they will be offered or how much they will cost. The government encouraged but did not require insurers to offer standardized options.
The standardized version of a midlevel silver plan has a $3,500 deductible, but primary care and specialty care visits, outpatient mental health services and prescription drugs are generally exempt from the deductible. In other words, consumers may face co-payments, but they do not have to meet the deductible before the insurance company starts to pay for such services.
On HealthCare.gov, the administration intends to introduce the idea of standardized options by describing Simple Choice as ''the easiest way to shop for plans.''
''All Simple Choice plans in the same category (like Silver) have exactly the same core benefits, deductibles and co-payments,'' states a message to be displayed on the federal website. ''When viewing Simple Choice plans, you can focus on other important features that may be different: monthly premiums, additional services covered, doctor and hospital networks.''
The Obama administration is still struggling to keep the Affordable Care Act affordable for many consumers. State officials have approved rate increases of 25 percent or more for many plans in 2017, after finding that insurers lost tens of millions of dollars in the exchanges. Aetna, UnitedHealth and other insurers have pulled back from the public marketplace, leaving consumers in many states with fewer choices.
Under the standardized version of a silver plan, co-payments would be $30 for a visit to a primary care doctor, $65 for a visit to a specialist, $15 for a generic prescription drug, $50 for a preferred brand-name drug and $100 for a nonpreferred brand-name drug. Consumers may be responsible for up to 40 percent of the cost of specialty drugs, including certain high-cost medicines for cancer, rheumatoid arthritis and multiple sclerosis.
For the lowest-income families, the charges would be lower.
Federal officials said they had studied several state-run exchanges -- in California, Connecticut, Massachusetts, New York, Oregon and Vermont -- that provide standardized options.
Peter V. Lee, the executive director of the California exchange, said standardized options had contributed to the stability and success of the marketplace there.
''Californians seeking coverage through the marketplace can easily compare health plans, knowing that every health plan has the same cost-sharing levels and benefits,'' Mr. Lee said.
Insurers generally dislike efforts to standardize health plans. Standardized options ''increase the complexity of the decision-making process'' by adding one more factor for consumers to consider, said America's Health Insurance Plans, a trade group.
In a letter this month to the Obama administration, Anthem, one of the nation's largest insurers, said, ''Standardized benefit designs threaten to commoditize insurance and stifle innovation, while potentially misleading consumers.'' The administration said insurers still had discretion to vary many features that would not be standardized.
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URL: http://www.nytimes.com/2016/10/18/us/affordable-care-act-health-insurance-simple-choice-plan.html
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The New York Times
March 25, 2012 Sunday
Late Edition - Final
Sunday Dialogue: Equitable Health Care
SECTION: Section SR; Column 0; Editorial Desk; LETTERS; Pg. 2
LENGTH: 1871 words
Readers respond to a writer's defense of the health reform law.
The Letter
To the Editor:
Starting on Monday, the Supreme Court will consider constitutional challenges to the Affordable Care Act, hearing arguments about Congressional authority to mandate the purchase of health insurance by individuals and threats to states' sovereignty by an expansion of state obligations under Medicaid.
Although not likely to be struck down in its entirety, the law will continue to face stubborn opposition accompanied by lingering charges that ''death panels'' will ration health care.
Many Americans mistakenly believe that Canada and Britain ration care while we do not. In reality, we also ration care, not through waiting lists but through high prices that impede access for those with no or limited insurance.
This inconvenient truth has been twisted into a convenient lie by reform opponents to confuse the public. The specter of rationing has also been invoked by those seeking to repeal the Independent Payment Advisory Board -- a panel that would recommend ways to lower Medicare costs -- so that Congress and special interests may retain firm control over Medicare spending cuts. By delegating responsibility to independent experts, such a board would help depoliticize the existing process.
Lost in the rhetoric is the Affordable Care Act's efforts to reduce rationing through mandatory coverage of preventive services and essential minimum benefits. The act holds promise for more rational allocation and consumption of scarce resources. But first, we must accept the fact that rationing already exists but needs to be made more equitable if we are to achieve better health for our citizens and better value for our health care dollars.
ALAN B. COHEN Boston, March 20, 2012
The writer is a professor of health policy and management at Boston University School of Management and executive director of its Health Policy Institute.
Readers React
Of course we now have rationing through financial access barriers. It's naive to pretend otherwise. The Affordable Care Act will help move some people into insurance and, through banning exclusion for pre-existing conditions, allow some to become insurable at reasonable rates for the first time. But it certainly will not fix everything and may even worsen some problems:
It does little to restrain overall health system costs, a most serious issue.
It does nothing to improve providers' unwillingness to accept Medicaid patients.
It fails to address fundamental problems with payment mechanisms and levels, as well as the training and distribution of health professionals.
So, like it or not, rationing will continue. Do we ration rationally, or do we let the free market set the rules?
Oregon instituted a widely supported Medicaid benefit package 20 years ago that faced these thorny rationing questions. Are the rest of us unwilling to catch up?
ANN ZUVEKAS Annandale, Va., March 21, 2012
The writer is a retired professor of health policy at The George Washington University.
Professor Cohen criticizes those who want to repeal the Independent Payment Advisory Board for invoking ''the specter of rationing.'' That ignores an immediate and crucial concern.
The board will be composed of 15 presidential appointees, unaccountable to the public. It will be given the task of cutting billions in Medicare expenditures -- largely by denying government reimbursement for new and innovative medicines.
In other words, its only viable option will be to further ratchet down reimbursement rates for providers, especially doctors, who are already losing money on Medicare patients. Indeed, according to the American Medical Association, the financial burden of too-low payments under Medicare has driven 17 percent of doctors and 31 percent of primary care doctors out of the Medicare program altogether.
If rates fall any lower, seniors will have an increasingly difficult time securing doctor appointments. Visits will be cut short to squeeze in patients and care compromised. The board is even more insidious because it deflects policy makers' attention from innovative reform efforts with real cost-saving potential.
PETER J. PITTS New York, March 21, 2012
The writer is president of the Center for Medicine in the Public Interest and a former associate commissioner of the Food and Drug Administration.
Professor Cohen's analysis represents common sense and logic. We do need ''more rational allocation and consumption of scarce resources,'' and the creation of the Independent Payment Advisory Board is the right step in that direction. It should be allowed to do its job.
I say this as an older retired American whose health care is paid for by Medicare. I understand that I may be among the first to take some hits from the rationing envisioned by Professor Cohen. So be it. In fact, I will applaud if one of the board's first acts is to rein in the enormous sums paid to keep the dying elderly barely alive for a few more weeks or months, when any life worth living is already gone. And let's rigorously re-examine whether every senior citizen is entitled to hip replacement.
The current health care system is unsustainable. If we do not get costs under control, the whole thing will soon collapse. I can only pray that enough Americans see through the political demagogy on this issue.
TOM BARKSDALE Woodstock, Ga., March 21, 2012
Professor Cohen points out that rationing occurs through price, which limits access for many. But there is another form of rationing: medical necessity clauses in benefits contracts used by all health plans. These clauses limit coverage to care that is deemed ''effective and appropriate.''
Decisions made by health plans about medical necessity are now confidential and not subject to public dialogue. The Affordable Care Act established a new entity -- the Patient-Centered Outcomes Research Institute -- to finance comparative research on the cost-effectiveness of treatments. Most health plans are likely to use the results of that research to inform their benefit decisions. The institute's work will be public and transparent. Isn't that far better than what we have in place today?
MARIANNE UDOW-PHILLIPS Ann Arbor, Mich., March 21, 2012
The writer is director of the Center for Healthcare Research and Transformation, based at the University of Michigan.
As a doctor I largely agree with Professor Cohen that the opposition to the Affordable Care Act is partly based on the ''specter of rationing,'' but I think we must be careful in advocating ''mandatory coverage of preventive services'' without being sure that this does not lead to excessive spending on unproven ''prevention.''
In the last few years, good science has shown that many adults, especially the well-to-do and hypochondriacal, receive excessive preventive services that don't prevent much of anything and, when they are of proven value, are done too frequently. I know elderly patients who still want such services as Pap smears, mammograms, colonoscopies, P.S.A. prostate tests, electrocardiograms, chest X-rays and blood chemistries on a regular basis, sometimes at the urging of their doctors.
Proven preventive care involves occasional measurement of blood pressure, proper immunizations, dietary and lifestyle advice when indicated, and very limited use of the above tests.
LONNIE HANAUER West Orange, N.J., March 21, 2012
Professor Cohen rightly observes that the Affordable Care Act would provide ''mandatory coverage of preventive services and essential minimum benefits,'' which would actually reduce the likelihood of rationing. This point must be appreciated in the larger context of inadequate health care in the United States compared with other industrialized nations.
For example, according to a 2002 study by the Institute of Medicine, 18,000 Americans die every year because they don't have health insurance; that figure was updated to 22,000 in 2006 by the Urban Institute. And in a recent Commonwealth Fund-supported study comparing ''preventable deaths'' in 19 industrialized countries, researchers found that the United States placed last.
But ultimately, even the Affordable Care Act is a stopgap strategy. The most promising approach to accessible and affordable health care in the United States is through a universal, single-payer insurance plan supported through tax revenues. As the doctor and medical anthropologist Paul Farmer has stated, ''no one should have to die of a disease that is treatable.''
RONALD PIES Lexington, Mass., March 21, 2012
The writer is a professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine.
Professor Cohen demonstrates that the new health care law will reduce ''rationing'' and make it more equitable.
Liberal critics should recognize that in today's unfortunate political climate, the Affordable Care Act is probably the only kind of law moving us closer to universal coverage that could have passed Congress.
The unanimous opposition among conservatives is ironic -- if they give even lip service to the notion of making health care available for all -- considering that the new law is the most conservative way possible to have moved in the direction of universal coverage.
The law would be widely popular if misleading propaganda had not clouded public understanding. True, it is flawed, but it is vastly better than relying on the market, which has created the most expensive, least equitable and most trouble-plagued health delivery system to be found in any advanced country.
MAX J. SKIDMORE Overland Park, Kan., March 21, 2012
The Writer Responds
Several excellent suggestions emerge from readers' letters, including comments about Oregon's experience with making thorny Medicaid spending decisions, the need to ''take some hits'' to rein in Medicare spending, and a desire to let the Patient-Centered Outcomes Research Institute perform its job. In addition, we should heed Dr. Hanauer's cautionary advice that only proven preventive services be mandated.
Mr. Pitts's attack on the Independent Payment Advisory Board, on the other hand, contains an apocalyptic vision of stifled innovation and compromised patient care wrought by ''insidious'' board decisions. This is what reform opponents and industry groups want the public to believe.
The reform act is clear on several points. The board may not restrict Medicare benefits, change eligibility criteria or ration care. The board will make recommendations for Medicare spending cuts if spending exceeds the limit for a given year. Congress may reject the board's recommendations, but it must propose alternatives that achieve similar savings. If Congress fails to act within a specified timeframe, the recommendations become binding.
Perhaps this is the real reason the House on Thursday voted to repeal the board (the Senate is not likely to follow suit). A House divided on Medicare spending is not likely to reach compromise under a deadline. The specter of rationing, thus, has been a ruse to prevent the loss of power over such decisions.
The reform act is imperfect. But the perfect must not become the enemy of the good. Let's hope that the Supreme Court will preserve most, if not all, of it and we can move forward.
ALAN B. COHEN Boston, March 23, 2012
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July 16, 2016 Saturday 00:00 EST
Obamacare's Kindest Critic;
Editorial
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 945 words
HIGHLIGHT: The Affordable Care Act has accomplished a lot, but too many people are still left out.
History will almost surely rank health care reform as one of President Obama's greatest accomplishments. About 20 million Americans have insurance that might otherwise have been unaffordable, and the law has cost much less than anticipated. But one senior administration official thinks the Affordable Care Act has fallen short. His name: Barack Obama.
Presidents usually wait until their memoirs to review their work. Not, in this case, Mr. Obama, who recently marked the act's sixth anniversary with an unusual article in The Journal of the American Medical Association. Health care costs are still much too high, he wrote, and 29 million people still lack coverage. He then sketched some ideas for the presumptive presidential nominees. Hillary Clinton is likely to listen, having proposed improvements of her own. Donald Trump, not so much. He has so far adopted the "repeal and replace" position of his party.
Six years ago, 16 percent of Americans did not have health insurance; that number is now down to 9.1 percent. People forced to pay out of their own pocket were often bankrupted. Some went without care, and others resorted to charity care at emergency rooms. The law has helped many of these people by expanding Medicaid, which insures the poor. For millions of others, it created health care exchanges where people could buy coverage with the help of government subsidies.
The act also required individuals to either buy insurance or pay a penalty (to help spread the costs), while mandating that businesses with more than 50 full-time workers provide insurance to their employees.
Also impressive is what the law has not done. Republicans who derisively labeled the program Obamacare said it would cost jobs and wreck the federal budget. Yet the economy has added more than 14 million jobs since Mr. Obama signed the measure, and, according to the Congressional Budget Office, the law has cost $157 billion, or one-quarter less than was forecast in 2010.
Still, too many people have been left out. For one thing, 19 states, including Florida, North Carolina and Texas, still have not expanded Medicaid, even though the federal government offered to pay the full cost for the first three years and 90 percent starting in 2020. If these states had opted in, four million more people would be eligible. But the Republicans who control the governments in these states are ideologically opposed to the health reform law.
And despite the subsidies, many people still can't afford health care. For some middle-class families who buy coverage on the exchanges, the cost of insurance and out-of-pocket expenses like co-pays and deductibles can add up to nearly a quarter of household income, according to the Urban Institute. It is no wonder then that nearly 80percent of those who still do not have insurance say they cannot afford it.
Mr. Obama proposes several fixes. He recommends that the government offer its own health insurance, a so-called public option, on the exchanges in some parts of the country. That could help make health care more affordable in rural areas and smaller cities where only two or three insurers sell coverage. Republicans and some moderate Democrats fear that this could be the first step to a single-payer health care system. But there might be more support for a policy that is intended strictly for people in places with few choices.
Mrs. Clinton supports the public option and has even suggested that people between the ages of 55 and 64 be allowed to buy into Medicare, though she has not yet provided details of how that would work. Mr. Trump has said he wants universal health coverage, and has proposed tax deductions and allowing insurers to sell policies across state borders. Tax deductions would help some people but wouldn't be enough, experts say. And insurers can already expand into other states as long as they follow the laws and regulations of the states in which they want to do business.
In addition to the public option, lawmakers ought to consider bigger subsidies for insurance offered through the exchanges, an idea Mrs. Clinton supports. This can be done at a modest cost paid for by slightly higher taxes, according to several experts. In addition, both federal and state governments ought to do more to educate people about the subsidies available to help them buy insurance.
The system could also be made more efficient. The Affordable Care Act has pushed insurers, doctors and hospitals to focus on preventive care, as Mr. Obama notes in his article, and lawmakers can build on that progress. Congress, he added, should allow Medicare to negotiate drug prices with pharmaceutical companies, an idea that could help lower costs but faces stiff opposition from Republicans and even some Democrats.
Yet another way to reduce spending on drugs, experts say, is to set up a system under which government pays more for effective medicines than for comparable drugs with less impressive results. The Obama administration recently proposed experimentally testing these and other changes within Medicare. The pharmaceutical industry is resisting and has pressured legislators to do so, too.
What Mr. Obama has done here is unusual - asking someone else to burnish a legacy of which he is personally proud. If the candidates (and Congress) pay attention, his request may also do a world of good for millions of Americans for whom decent health care remains out of reach.
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June 28, 2012 Thursday
Will Time Heal Health Care Wounds?
BYLINE: ANDREA LOUISE CAMPBELL
SECTION: OPINION
LENGTH: 912 words
HIGHLIGHT: Changing levels of support for health-care reform in Massachusetts give us some idea of what to expect now.
When the Supreme Court declared the Affordable Care Act's provision for an individual mandate to buy medical insurance constitutional, the majority did so by placing the mandate within Congress's power to tax rather than under the Commerce clause. While the decision keeps most of the law intact, what does it mean politically? And how will the characterization of the mandate as a tax play among supporters and opponents of the legislation?
Supreme Court rulings on politically prominent issues can have three effects on subsequent attitudes among the public: legitimation, backlash or polarization. As Nathan Persily, Jack Citrin and Patrick Egan show in their 2008 book, "Public Opinion and Constitutional Controversy," legitimation occurs when public opinion moves in line with the court, as it has over time with regard to the 1954 Brown v. Board of Education school integration decision and to gender equality decisions like Stanton v. Stanton in 1975, which invalidated laws predicated on traditional gender roles that differentiated between men and women in the allocation of government benefits.
Backlash occurs when public opinion moves directly in opposition to the court's ruling, as when the public shifted, more in favor of school prayer and against flag burning after controversial decisions on those issues. Crucially, under polarization, overall opinion does not shift but different groups move in opposite directions. Examples include the gap in abortion opinion that grew between Protestants and Catholics after Roe v. Wade in 1973 and the difference between liberals and conservatives that widened after the Lawrence v. Texas gay rights decision in 2003.
A look at public opinion during the first few years after the Massachusetts health care reform in 2006 offers some insights into what might happen now at the national level. Although there has not been a legal challenge as dramatic as the suits against the Affordable Care Act, the Commonwealth's experience does show how public opinion changes with health reform implementation. Of course, the Massachusetts case is different because it is a state-level reform that cannot elicit the objections to federal intervention that the Affordable Care Act. does, and yet the case is informative because the underlying structure of the reform is nearly identical. So what happened? There is evidence of both mild legitimation and pronounced polarization.
Polls by the Harvard School of Public Health in the first years after the law was implemented show that both the health reform overall and the individual mandate became more popular. Support for the Commonwealth's reform increased from 61 percent in September 2006, shortly after implementation began, to 69 percent two years later, in June 2008. Similarly, support for the individual mandate increased from 52 to 58 percent. Overall support for the reform has dropped and risen since, with the percentage in favor of the mandate falling back to 51 percent. It is not always steady progress.
There is also evidence of sharp partisan polarization over the issue: Democrats became more supportive of the reform and the mandate while Republicans became more opposed, despite the fact that the legislation was signed by a Republican governor (after having passed the Democrat-controlled state legislature). In 2006, Democrats were 12 points more likely than Republicans to support the law (68 to 56 percent). By 2008, that gap had grown to 32 points (76-44). Similarly, Democrats were 5 points more likely than Republicans to support the individual mandate in 2006 (56 to 51 percent), a gap that grew to 17 points two years later (65 to 48 percent).
Politically we might expect similar polarization at the national level. While increased familiarity and experience with the new legislation may enhance overall support in ways that might elate proponents of the law, implementation also seems to breed antagonism, perhaps precisely because opponents find such success threatening. That the court's ruling defines the mandate's penalty as a tax opens up opportunities for damning rhetoric from the reform's opponents as well. Already we are hearing reminders that candidate Obama promised not to raise taxes on the middle class. As Sarah Palin wrote on Facebook after the court released its decision, "Obama promised the American people this wasn't a tax and that he'd never raise taxes on anyone making less than $250,000." Now, she said, we "see that this is the largest tax increase in history." Glenn Beck's Web site agreed: "No taxes on the middle class? Lies! Obamacare now Obamatax."
However, a large group - both in Massachusetts and nationwide - are political Independents, whose opinions are informative because they are one group not constrained by partisanship. Their support for the Massachusetts reform and mandate grew over time, from 60 to 70 percent for the overall reform, from 53 to 58 percent for the individual mandate. With Democrats and Independents constituting a majority of voters nationwide, supporters of the Affordable Care Act may not just celebrate the law's survival but also have good reason to expect that its popularity will increase - if the law, having made it through the Supreme Court, now also survives the political threat of a Republican repeal effort.
Seven Consequences of the Health Care Ruling
The Liberal Embrace of Judicial Restraint
Could Defeat in Court Help Obama Win?
Sex and the Secularists
States Are Good Guinea Pigs
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(Economix)
February 20, 2013 Wednesday
Wages and Employer Penalties
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 389 words
HIGHLIGHT: The employer penalties under the Affordable Care Act may have the effect of reducing wages, particularly because the penalties are not tax-deductible, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The cost to workers of the Affordable Care Act's employer responsibility penalties is greater than you think, because of their business tax treatment.
Most low-skill workers are not offered health insurance by their employers, and those employers have been complaining about the $2,000-per-employee annual penalty they will pay beginning next year ($3,000 per employee who resorts to a subsidized exchange when insurance offered by the employer is deemed unaffordable to the worker).
Next year will not be the first time that employers had to pay taxes based on the number of employees they have. For example, they have been paying payroll taxes that amount to almost $2,000 per year for an employee with a $25,000 salary.
Employer payroll taxes have been extensively studied, and economists have concluded that employees ultimately pay for those taxes in the form of lower wages.
Thus you might think that the new $2,000 penalty would reduce wages by about $2,000 per employee per year. But unlike employer payroll taxes, the employer responsibility levies are not deductible from employer business taxes. To have the same after-tax profit, an employer in the 39 percent bracket (a typical state-plus-federal bracket for corporations) would have to cut wages by $3,046.
An employer paying the $3,000 penalty would have to cut wages by $4,569. That would push someone working full-time at $10 per hour down to minimum wage.
Some good news for the employees who want health insurance: the employer penalties come with employee access to large federal subsidies for purchasing health insurance and paying out-of-pocket health expenses, unless you are in a family that is 400 percent or more above the poverty line.
Not all employers have to pay the penalties, and more good news for employees is that both types of employers will compete with each other in the market for labor, which might prevent penalty-paying employers from passing on the full cost to their employees.
Staying Ahead of the Tax Man
College Premium: Better Pay, Better Prospects
Older Workers Could Benefit if Companies Drop Insurance
The Incomes of Physicians
Are Immigrants Taking Your Job? A Primer
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(The Caucus)
September 30, 2013 Monday
Obama Selects Romney Adviser for Social Security Commission
BYLINE: ASHLEY SOUTHALL
SECTION: US; politics
LENGTH: 349 words
HIGHLIGHT: On the eve of open enrollment in health exchanges created under the Affordable Care Act, President Obama announced that he wanted to hire Lanhee J. Chen, a Mitt Romney adviser who argued for the law’s repeal.
President Obama announced on Monday that he planned to nominate Lanhee J. Chen, the top policy adviser to Mitt Romney's 2012 presidential campaign, to fill an opening on an independent federal panel whose task is to recommend improvements to Social Security.
The announcement of Mr. Chen's nomination was peculiarly timed, just a day before the health insurances marketplaces created under the Affordable Care Act - which Mr. Chen has argued should be repealed - can begin accepting customers.
Mr. Chen, 35, was born in North Carolina to parents who immigrated from Taiwan. He earned four degrees from Harvard University, where he was active in Republican politics. He is currently a research fellow at the Hoover Institution and a professor of law and public policy at Stanford University.
Mr. Chen, who specializes in health care policy, has worked in academia, campaigns and government, including stints as a health care adviser to the Bush-Cheney ticket in 2004 and as a domestic policy adviser on Mr. Romney's 2008 presidential campaign. In 2008, he was also a senior counselor to the deputy secretary of Health and Human Services.
In 2010, he was the deputy campaign manager of Steve Poizner's California gubernatorial campaign for eight months, before leaving in August to become a visiting scholar at the University of California's Institute of Governmental Studies. He worked four months as the policy director of Mr. Romney's Free and Strong America PAC, before he was tapped in April to join Mr. Romney's 2012 presidential campaign as policy director.
Mr. Obama will nominate Mr. Chen to serve on the Social Security Advisory Board, a bipartisan panel of seven experts, who serve six-year terms and must be confirmed by the Senate.
An earlier version of this post misstated where Lanhee Chen was born. He was born in North Carolina to parents who immigrated from Taiwan; he was not born in Taiwan.
Lawmakers Point Fingers Over Budget Deadlock
The Early Word: Escalating
Obama Defies Critics With State Dept. Choice
The Early Word: Pre-Existing Conditions
Republican Effort to Unpack the Court
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January 28, 2016 Thursday
Late Edition - Final
Oklahoma Resists a Push for Enrollment in Affordable Care Act Coverage
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 1419 words
OKLAHOMA CITY -- A resolute band of insurance counselors, undeterred by the politics of health care in this staunchly conservative state, is increasing its efforts to find people who are uninsured and enroll them in coverage before the Affordable Care Act's third annual open enrollment period ends on Sunday.
But the push is facing Dust Bowl-force headwinds in one of the states most hostile to the health law -- from some Oklahoma officials and from residents who mistrust all things federal.
The state declined to set up an insurance exchange or to expand its Medicaid program, which has some of the nation's most restrictive eligibility criteria. State officials say the number of private insurers participating on the federal insurance exchange here has fallen, and the premiums of the insurance plans on offer have increased.
The public's attitude can also be an obstacle: Supporters of the Affordable Care Act often encounter stony skepticism here.
'' 'Obamacare' is a cuss word in this state,'' said former Gov. David Walters, a Democrat.
Steven Goldman, an insurance counselor at the Oklahoma Primary Care Association, which represents community health centers, said, ''Consumers come in because they want and need health insurance, but they have trepidation because they believe this is a government insurance plan with government doctors.''
In fact, he noted, the health plans available here on HealthCare.gov are offered by private companies: Blue Cross and Blue Shield of Oklahoma and UnitedHealth Group.
More than 133,000 Oklahomans have selected health plans or had coverage automatically renewed through HealthCare.gov since open enrollment began on Nov. 1. In this state of 3.9 million people, about 800,000 are enrolled in Medicaid. But nearly 600,000 were still uninsured in 2014, according to the latest data from the Census Bureau, and getting them covered will not be easy.
''There are not a lot of positive messages about the Affordable Care Act in Oklahoma,'' Mr. Goldman said.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, says he hopes to overcome those doubts when he visits Oklahoma this week to highlight the open enrollment deadline. Nationwide, more than 11.5 million people have selected health plans or been automatically re-enrolled, with at least 8.8 million coming through HealthCare.gov and 2.7 million through state-based marketplaces.
In many other cities, like Milwaukee and Philadelphia, public officials are enthusiastically promoting enrollment in advance of the deadline. In this state, where President Obama lost all 77 counties in the elections of 2008 and 2012, insurance counselors and community health workers have been left to lead the fight.
''Obamacare is toxic,'' said Craig W. Jones, the president of the Oklahoma Hospital Association, who wishes the state would expand Medicaid. ''There has been absolutely zero sentiment in the Legislature to even think about expansion of the Medicaid program.''
Consumers who are eligible for insurance subsidies, in the form of tax credits, worry that they are getting something others cannot. Many Oklahomans have a strong streak of independence and are reluctant to rely on federal assistance. When told of their subsidies, Mr. Goldman said, consumers ask: ''Am I getting more than I deserve? Have I earned this? Is it fair?''
Even Oklahomans generally satisfied with their coverage report some difficulties. Lucia Perri, 49, of Guthrie, an accountant, said she was pleased with her Blue Cross and Blue Shield policy. The premium is $538 a month. But with a federal subsidy of $440, she pays $98 a month.
Still, she said, she had difficulties enrolling, then renewing her coverage and determining the amount of her subsidy online at HealthCare.gov.
''I don't like the way the government is administering this program,'' Ms. Perri said. ''There are too many surprises.''
Another problem stems from the decisions of state officials, whose refusal to expand Medicaid under the health law has created ''this chasm of a no man's land,'' said Lou Carmichael, the chief executive of Variety Care, a community health center with more than a dozen clinic sites in Oklahoma.
Many Oklahomans have too much income to qualify for Medicaid under state rules, but not enough to qualify for subsidies to help them buy private insurance in the federal marketplace.
''Many of the people we see are destitute,'' Ms. Carmichael said. ''But they fall into the gap, and there is little we can do to help them.''
In Oklahoma, parents with dependent children generally cannot obtain Medicaid if their household income is more than about half of the poverty level -- higher than $9,240 for a three-person family. Adults generally cannot get Medicaid at all if they do not have dependent children and they are not elderly, disabled or pregnant.
In states that have expanded eligibility under the health law, Medicaid is available to people with annual incomes up to 138 percent of the poverty level, up to $27,724 for a three-person family and $16,242 for an individual. And states that have expanded Medicaid eligibility have generally had much broader gains in insurance coverage.
''Consumers come in, eager to see their coverage options,'' said Jesus Frias, an insurance counselor at Variety Care. ''We go through their case, we help them apply, and often we find that they are not eligible for Medicaid or subsidized coverage in the marketplace.''
James E. Cooksey, 54, visited the Health Department here last week and left with nine prescriptions for drugs to treat very high blood pressure and diabetes. Mr. Cooksey said his minimal income came from work as a Salvation Army bell-ringer in the holiday season and from odd jobs like mowing lawns. But he does not qualify for Medicaid because he lives alone and has no dependent children.
''I've still got my mind,'' Mr. Cooksey said, ''but my body is failing me. And I'm not getting any help.''
For some, the state's attitude is mystifying.
''If we have an ice storm, the governor is on the phone begging for federal money,'' said Mr. Walters, the former governor. ''If we have a tornado, everyone is lining up for federal money. And we take federal highway funds. It's just the Obamacare dollars that are radioactive.''
But for conservatives like Jonathan Small, the president of the Oklahoma Council of Public Affairs, it is a matter of prudence. The state cannot afford the Medicaid program it has, much less a larger program, he said. The federal government pays 100 percent of the cost of newly eligible Medicaid beneficiaries from 2014 to 2016, with the federal share declining gradually to 90 percent in 2020 and beyond. Critics of the health care law worry that in the future, the federal government might reduce its promised contribution.
Then there are the rising costs, which have bedeviled many states. Premiums had been lower here than in many states. But, according to the federal Department of Health and Human Services, the cost of a benchmark insurance plan increased by an average of 35.7 percent this year in Oklahoma, more than in any other state using the federal exchange.
And while the Obama administration says the Affordable Care Act has increased competition among health plans, in Oklahoma, the number of carriers on the exchange has declined to two, from four in 2015, said State Representative Glen Mulready, a Republican who is the chairman of the House Insurance Committee.
Oklahoma's economy and state finances have been battered by a steep decline in oil prices, which reduced state revenue. The state Medicaid agency reduced payment rates for hospitals and other health care providers by 3 percent this year.
Hospitals and others who support the expansion of Medicaid say it would bring an infusion of federal money into Oklahoma.
Oklahomans such as Mary C. Reynolds, a 60-year-old musician who recently renewed her coverage through the marketplace, see the benefits of the health law as well as its shortcomings. It enabled her to obtain insurance, which she had been denied for more than a decade because of a heart problem. But ''it was a hassle to change to a new doctor'' last year, she said, and she did not understand why her old doctor was no longer in her plan.
''My experience with the Affordable Care Act,'' she said, ''has been a mixed bag.''
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URL: http://www.nytimes.com/2016/01/28/us/politics/oklahoma-resists-push-for-enrollment-in-affordable-care-act-coverage.html
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GRAPHIC: PHOTO: Steven Goldman, right, helping John and Patti Elliot enroll under the Affordable Care Act in Oklahoma City on Monday. (PHOTOGRAPH BY BRETT DEERING FOR THE NEW YORK TIMES)
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February 5, 2014 Wednesday
A Report's Real Message: It Wasn't About Health Care
SECTION: BUSINESS; economy
LENGTH: 1000 words
HIGHLIGHT: A Congressional Budget Office study that assessed the labor market impact of the Affordable Care Act was more notable for its stark warning about the fiscal damage from diminished growth, an economist writes.
Jared Bernstein is a senior fellow at the Center on Budget and Policy Priorities in Washington and a former chief economist to Vice President Joseph R. Biden Jr.
Only in Washington could the following occur: the Congressional Budget Office releases a dense, technical report wherein it tweaks its estimates of how labor supply will be affected by the health care act over the next decade ... and the whole town goes nuts.
Not only that, but in our mass nuttiness, we missed the actual message from that potboiling page-turner also known as the Budget and Economic Outlook, 2014-2024. That message had almost nothing to do with the Affordable Care Act. It was instead a stark warning about the damage to our fiscal outlook from diminished economic growth, jobs and incomes.
First, let us dispose of the Affordable Care Act silliness, at least among ourselves (as much as I'd like to, I can't stop the warring parties down here from their predictable responses). Those who want to bash the health care act argue that it's a job killer, and thus they latched onto the budget office's estimate that there will be "a decline in the number of full-time-equivalent workers of about ... 2.5 million in 2024."
Sounds like a job killer, right?
Wrong. There's a difference between workers (labor supply) and jobs (labor demand). The budget office bent over backward to make this distinction, claiming that employers' demands for workers will not change much at all because of the health care law.
So what do you get when there's less labor supply around stable labor demand? A tighter job market.
The economist Dean Baker uses Congressional Budget Office numbers to make this point:
"If hours fall by 1.5 to 2.0 percent, but compensation falls by 1.0 percent, then compensation per hour rises by 0.5-1.0 percent due to the ACA. If this is bad news for workers then someone must have been enjoying the new found freedoms in Colorado or Washington State too much."
There is thus no support in the Congressional Budget Office report for the claim that the health care act kills jobs. As the report put it, the estimated reduction in hours of work "stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses' demand for labor."
In fact, as some of the fog is clearing in our benighted capital, a smidgen of clearer thinking is breaking through. What the Congressional Budget Office is saying is that because people receiving subsidies through the health care act will see those subsidies reduced as their earnings rise, they'll choose to work less to avoid that loss.
An editorial in The New York Times on Wednesday provides a positive view of this impact of the law, stressing that if those locked into a job because of a pre-existing condition or working more hours than they'd like in order get health coverage now have a choice to do otherwise, isn't that a plus?
The principled conservative response to this, which I haven't seen anywhere, is not "but it's a job killer!" Remember, the job still exists. The Affordable Care Act gives that job holder an option and, for some, an incentive to work less without losing health coverage. Conservatives might well object to making that choice on the taxpayers' dime. But there's no model of health care reform from the left or the right that doesn't involve a subsidy that fades out as income rises. So this labor-supply-choice problem is endemic.
Were we to have a real debate on what the budget report is saying, we would instead focus on what to do about the truly disturbing news in the chart below. The chart, using Congressional Budget Office data also released Tuesday, compares the office's "guesstimates" of potential growth in gross domestic product, inflation-adjusted, made in 2007 (orange line) and most recently (blue line). "Potential G.D.P." is how much the economy should be expected to produce when we're in the midst of a robust recovery with our economic resources fully deployed.
Clearly, something happened between these two periods that led to an economically large and significant decline in this key indicator. What was it?
You might think, "demographics!" - we're getting older, more workers are retiring, and we should thus expect slower growth. Except that there's little known about the age structure of the work force now that wasn't known in 2007 when the Congressional Budget Office made its more optimistic forecast.
What happened was a huge housing bubble inflated by "financial innovation," which brought us the great recession and the slow slog we've come to know as the current recovery. At least by the budget office's estimates, the damage from that period is now baked into the cake.
In fact, the budget office reported Tuesday that the fiscal outlook has worsened slightly, as it now expects the budget deficit over the next decade to exceed its previous forecast by 0.5 percent of G.D.P. This increase in the deficit has nothing to do with actual fiscal policy (taxing and spending decisions that are on the books). It is fully a function of the expectation of slower growth spinning off fewer revenues.
Actually, let me correct myself. The decline in potential G.D.P. has a lot to do with fiscal policy ... lousy fiscal policy that injected large doses of austerity into the United States economy when it clearly needed the opposite. I believe the damage can be reversed - that the blue line can come up closer to the orange line - with much better policy that focuses on job creation, better pay and increased opportunity. If so, an added benefit of that reversal would be a much stronger fiscal outlook.
But we'll never get there if we're mired in foolish debates that have nothing to do with the facts of the case.
The Unemployment Rate at Full Employment: How Low Can You Go?
Little Sign of Jobs Impact From Health Care Law
Medicaid and the Incentive to Work
Game-Changing Investments for the U.S.
Breaking Out of a Cramped Economic Policy Debate
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(The New Old Age)
February 14, 2013 Thursday
A New Commission: Time to Cheer or Yawn?
BYLINE: PAULA SPAN
SECTION: HEALTH
LENGTH: 760 words
HIGHLIGHT: In place of the Class Act, Congress created a Commission on Long-Term Care. Some doubt it will lead to anything.
The fate of the Class Act, which would have established the nation's first voluntary public long-term care insurance program, was sealed in 2011 when the Obama administration shut it down, essentially calling it unworkable.
As long as the language remained part of the Affordable Care Act, supporters allowed themselves to hope, or perhaps fantasize, that the administration might return to the subject. How to care for an aging population, and who pays for that and how, are questions that won't go away.
But Congress quietly administered the coup de grâce last month, during the fiscal cliff negotiations. The budget deal stripped the Class Act language from the Affordable Care Act. R.I.P.
In its place -- thanks to the intervention of Senator Jay Rockefeller, Democrat of West Virginia -- the negotiators created a Commission on Long-Term Care, charged with developing plans for "a comprehensive, coordinated and high-quality system" ensuring long-term care for older adults and people with disabilities.
Its 15 members -- three picks each for the president, the Senate majority and minority leaders, and the House speaker and minority leader -- face a tight deadline. Within six months, they are supposed to recommend legislative or administrative actions, including actual legislative language. Then bills are to be introduced in both houses of Congress on the very next day they are in session.
Which sounds like urgency, but is it? Even Connie Garner, the longtime Kennedy staff member who directs the advocacy group called Advance Class, was skeptical. "What can you really do in six months?" she said. Actuaries and policy types had been working on the Class plan for 19 months before the plug was pulled. "And so what if you introduce a bill?" she went on. "You can introduce stuff and nothing happens."
So when Advance Class held its monthly board meeting a few days after the Class Act officially bit the dust, Ms. Garner figured this push for a national long-term care approach was dead, along with her organization. She had prepared a valedictory, praising the group for at least putting the issue on the national agenda.
"But they said, 'No, we're going to keep Advance Class going; we're going to fight the long fight,' " she recalled. So on we go.
Discouragingly, the commission has already hit delays: Its members were to be named within 30 days of the budget deal's enactment, but only the Congressional Democrats have made appointments.
Senator Harry Reid, the majority leader, nominated a veteran health policy scholar, Judy Feder, who is now at the Georgetown University Public Policy Institute; the labor executive Laphonza Butler, who heads California's United Long-Term Care Workers Union; and Javaid Anwar, a Nevada internist.
Representative Nancy Pelosi, the House minority leader, appointed Bruce Chernof, chief executive of the SCAN Foundation, which promotes quality care for the elderly; Judith Stein, founder of the Center for Medicare Advocacy; and George Vrandenburg, a retired corporate lawyer who has put his philanthropic muscle behind Alzheimer's causes.
We have heard nothing yet from the White House or the Republican Congressional leadership.
Maybe that barely matters. "I can't imagine anything coming out of this commission that won't be totally forgotten a year from now," said Jesse Slome, executive director of the American Association for Long-Term Care Insurance. "How many commissions have there been?"
Yet one thing that he and the proponents at Advance Class can agree on -- maybe the only thing -- is that this issue demands attention.
Otherwise, Mr. Slome says, we are stuck with what we have when it comes to older people who might need expensive care for 30 years, and disabled people who might need care for even longer. And what we have, he said, amounts to "a little here, a little there, a little Medicare, a lot of Medicaid, a little long-term care insurance and a lot of unpaid family caregiving." (I would say very little long-term care insurance, and a vast amount of unpaid family care.)
Discussing the future of Medicare and Medicaid without including long-term care is pointless, Mr. Slome added. Ms. Garner notes that she meets frequently with Republicans and that they never dismiss the issue as unimportant.
Well, there's a start.
Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."
New Life for the Class Act?
Behind the Class Act, a Numbers Game
The Curtain Rises on the Class Act
Uncle Sam Wants You (Yes, You)
Good News and Bad on Long-Term Care
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(You're the Boss)
August 22, 2013 Thursday
Employer Mandate, Delayed by Paperwork (and Efforts to Reduce It)
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 974 words
HIGHLIGHT: The challenge of writing regulations that put the Affordable Care Act’s requirements for employers into practice, and then getting computer systems to carry them out, proved too much, too soon.
Over the last several weeks, we've taken a close look at the Affordable Care Act's employer mandate, which requires companies with at least 50 employees to provide affordable health insurance to workers or pay a penalty. We've examined, among other issues, how the mandate defines affordable, how it treats workers whose hours vary - even whether it could be used as catalyst for hiring formerly undocumented immigrants.
None of these complications, though, explain why the Obama administration decided to delay putting the mandate into effect for a year. According to administration officials, including President Obama himself in a recent interview with The Times, the provision was snagged on the reporting requirements it imposes on businesses.
The employer mandate works two ways. First, if a company with 50 or more full-time employees does not offer insurance, and at least one employee buys individual insurance with a government subsidy, the company pays a penalty. And businesses that offer insurance may have to pay a penalty if their employees reject the offer because the insurance does not meet the health law's minimum standards or it is unaffordable. But in order to impose a penalty on any business, the Internal Revenue Service will rely on information that the company itself must supply. And for businesses, this was proving contentious.
Among other things, the law (specifically, in the newly created Section 6056 of the Internal Revenue Code) requires businesses subject to the mandate to certify beginning in 2014 whether or not they offer insurance that meets the law's requirements to cover full-time employees. If so, then the company - businesses subject to the mandate are called "applicable large employers," even though most of them for practical purposes are small - must also report for which months coverage was available; the premium of the "lowest cost option in each of the enrollment categories under the plan"; the length of any waiting period; and the company's share of the "total allowed costs of benefits provided under the plan."
Each company must also report the number of full-time employees for each month of the year, as well as the name, address and taxpayer identification number of each full-timer. The information return must also indicate for which months each employee had company health coverage. The first of these annual reports, for 2014, would have been due by the end of January 2015, had the provision not been delayed.
In early 2012, the I.R.S. requested comments on what the rules to carry out these requirements should look like, but by the middle of 2013 it had not drafted any regulations. Organizations representing employers were starting to become antsy, about both the prospective complexity of the requirements and the lack of precise detail about them.
"There's a lot of I.T. behind this, and data collection and reporting that needs to happen," said Michelle Neblett, director for labor and work-force policy at the National Restaurant Association, a trade group. "Bringing all those systems together in a way that they can communicate with each other, that the information can come together and be reported in the way the government will require, can be a daunting task."
Neil Trautwein, employee benefits policy counsel at the National Retail Federation, said businesses had expected initial rules last year. "We've warned repeatedly that even though we're working hard to come into compliance, we can't do that without the regulations to tell us how to do it and build the systems," he said.
But beyond concerns about time pressures, business groups want to shrink the scope of reporting. For example, Ms. Neblett said, only employees who earn 100 to 400 percent of the federal poverty level would be eligible for government subsidies to buy individual insurance, "so do we need report on everybody, or do we just focus on the employees who could potentially trigger the employer penalty?"
The United States Chamber of Commerce, in its comments about interpreting the statute, went even further, and argued that only "employers who are likely to be fined either for failing to offer coverage or because their employees are likely to receive a tax credit" are subject to the reporting requirement, not every large employer required to offer insurance.
A close reading of the law may not support that. The first paragraph of Section 6056 begins, "Every applicable large employer required to meet the requirements of [the employer mandate] with respect to its full-time employees during a calendar year shall, at such time as the secretary may prescribe, make a return." But businesses appear to have found sympathetic ears at the White House on that count, and on the time to prepare.
"The majority of employers in this country provide health insurance to their employees," President Obama said in his Times interview. "And the number of employers who are potentially subject to the employer mandate is relatively small.
"The way the law was originally written, it did not take into account the fact that we don't necessarily need to load up the vast majority of companies that are already doing the right thing with a bunch of additional paperwork; are there simpler ways for us to allow them to certify that they're providing health insurance? And if they do that, then the purpose, the spirit, of the law is met, and we can concentrate on the few bad actors who are unwilling to provide health insurance to their employees even though they can afford it, and they're relatively large employers."
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
It's the Affordable Care Act. But What Is Affordable?
In the Affordable Care Act, Some Children Left Behind
A Bakery Is Relieved to Have the Employer Mandate Delayed
Could Employers Use Immigrants to Avoid the Health Mandate?
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March 23, 2016 Wednesday
Late Edition - Final
Medicare Proposal Takes Aim at Diabetes
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 901 words
WASHINGTON -- The Obama administration plans on Wednesday to propose expanding Medicare to cover programs to prevent diabetes among millions of people at high risk of developing the disease, marking the sixth anniversary of the Affordable Care Act with the prospect of a new benefit, federal officials said.
Sylvia Mathews Burwell, the secretary of health and human services, is scheduled to announce the proposal at a Y.M.C.A. here. Under the plan, Medicare would pay for certain ''lifestyle change programs'' in which trained counselors would coach consumers on healthier eating habits and increased physical activity as ways to prevent Type 2 diabetes, formerly called adult onset diabetes. Such programs have been found effective in people with a condition known as prediabetes, meaning that they have blood sugar levels that are higher than normal but not high enough to be considered diabetes.
That expansion was made possible by provisions of the Affordable Care Act, which President Obama signed six years ago Wednesday.
The Centers for Disease Control and Prevention estimates that 86 million adults, including at least 22 million people 65 or older, are prediabetic, increasing their risk of heart disease, stroke and diabetes itself.
In 2012, the National Council of Y.M.C.A.s, also known as Y.M.C.A. of the U.S.A., received a federal grant of nearly $12 million to test the value of a diabetes prevention program in eight states. The curriculum for the program was approved by the C.D.C.
After a formal evaluation, Ms. Burwell said, ''this program has been shown to reduce health care costs and help prevent diabetes.''
Federal officials said that Medicare saved $2,650 for each person enrolled in the prevention program over 15 months, compared with similar beneficiaries not in the program. That was more than enough to cover the costs. In addition, officials said, Medicare beneficiaries in the program lost about 5 percent of their body weight, which was enough to reduce substantially the risk of future diabetes.
Under the 2010 law, the health secretary can, by regulation, expand such demonstration projects nationwide if she finds that they would reduce Medicare spending without reducing the quality of care, and if the Medicare actuary agrees. That is a major change from the situation before the health care law, when an act of Congress was generally required to make even minor changes in Medicare benefits.
The proposal must go through a public comment period, but without the need for congressional approval, there is little doubt it will go into force before Mr. Obama leaves office.
Ms. Burwell said the counseling for people with prediabetes was the first preventive service to become eligible for expansion into the Medicare program under the Affordable Care Act.
Dr. Matt Longjohn, the chief health officer at the national Y.M.C.A. organization, said the results of the demonstration project vindicated the role of ''lay health workers'' in preventing chronic disease. These workers, he said, delivered preventive services at a much lower cost than doctors, nurses and other health professionals, and the services were ''just as effective in terms of weight loss.''
Private insurers have also begun to cover diabetes prevention services like those provided by Medicare and the Y.M.C.A.s.
''The program helped me a lot, and I hope it helps other folks,'' said Timothy L. Enfinger, a 45-year-old nuclear licensing engineer in Wilmington, N.C., who received the service through UnitedHealthcare and his employer, General Electric.
He said in an interview that he had lost 35 pounds, lowering his weight to 240 pounds. And he told the government: ''I was pretty much your standard couch potato before the program. Now my wife and I go walking every day, sometimes as much as two and a half miles. I feel a lot better.''
Services covered by the proposed diabetes prevention benefit could be provided in person or online. Omada Health, a San Francisco company founded in 2011 with venture capital, says it has provided diabetes-prevention services online to more than 45,000 people, most of whom had employer-sponsored insurance.
''With Medicare coverage, our work with seniors is likely to grow dramatically,'' said Mike Payne, the head of medical affairs at Omada.
Prediabetes is treatable, federal officials said, but only about 10 percent of people with the condition are aware they have it. Left untreated, up to one-third of people with prediabetes will develop diabetes within five years, the government says. People can use a test devised by the C.D.C. to assess their risk of prediabetes.
The government has not said how it would pay for diabetes prevention services. Medicare could reimburse providers directly or could pay for their services as part of a package that also includes the services of doctors who monitor the progress of patients.
Omada executives said that health insurers and employers paid the company $650 to $800 in the first year for each person who successfully completed its program and lost weight, reducing the risk of diabetes. But Medicare could use a different approach. Medicare officials will set forth details of payment in a proposed regulation that will be open to public comment.
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URL: http://www.nytimes.com/2016/03/23/us/politics/medicare-proposal-takes-aim-at-diabetes.html
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February 3, 2017 Friday
Late Edition - Final
Sprint to Repeal the Health Law Slows to a Crawl
BYLINE: By ROBERT PEAR and REED ABELSON
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1302 words
WASHINGTON -- Congress's rush to dismantle the Affordable Care Act, once seemingly unstoppable, is flagging badly as Republicans struggle to come up with a replacement and a key senator has declared that the effort is more a repair job than a demolition.
''It is more accurate to say 'repair Obamacare,''' Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said this week. ''We can repair the individual market, and that is a good place to start.''
The struggles and false starts have injected more uncertainty into insurance markets that thrive on stability. An aspirational deadline of Jan. 27 for repeal legislation has come and gone. The powerful retirees' lobby AARP is mobilizing to defend key elements of the Affordable Care Act. Republican leaders who once saw a health law repeal as a quick first strike in the Trump era now must at least consider a worst case: unable to move forward with comprehensive health legislation, even as the uncertainty that they helped foster rattles consumers and insurers.
Insurers are threatening to exit the Affordable Care Act's market unless the Trump administration and Congress can quickly clarify their intentions: Will they support the existing public marketplaces, encourage people to sign up and keep federal assistance flowing to insurers, or not?
''We need some certainty around the rules,'' said Dr. J. Mario Molina, chief executive of Molina Healthcare, which has been a stalwart in the Affordable Care Act market and is making money under the system.
''We have a few months, but we don't have a lot of time,'' he said.
With the official end on Tuesday of what was supposed to be its final open enrollment season, the Affordable Care Act is looking more resilient than it seemed just a month ago. It will still be several days before final enrollment figures are released, and although a surge of last-minute signups failed to have materialize amid talk of repeal, early indications did not point to a collapse.
At their annual retreat last week, in Philadelphia, several congressional Republicans edged away from their powerful promise to ''repeal and replace'' the Affordable Care Act. It would, they said, be more accurate to say they intend to fix a law that they blame for the cancellation of many insurance policies, soaring premiums and a shrinking choice of health plans in many states.
Many Republicans say their resolve to dismantle the law, a central element of President Barack Obama's legacy, is undiminished. ''We are looking to repeal this law, just like we told the voters we were going to do, just like we promised them we would do,'' said Representative Jim Jordan, Republican of Ohio and a leader of the House's most conservative wing. ''After all, there was an election where that was one of the most important issues.''
But after waging and winning many elections with a promise to kill it, Republicans still have no agreement on how to replace it. They will, they say, pursue a piecemeal approach because they have no desire to supplant the giant 2010 health law with a single comprehensive Republican plan cooked up in Washington.
When Congress convened this year, Republicans immediately introduced a budget resolution clearing the way for legislation to gut the health law, with strong support from Mr. Trump, who took office 17 days later. But Mr. Trump's rocky start has slowed the momentum, depleting his political capital and dimming prospects for bipartisan cooperation.
In addition, many senators are preoccupied with fights over the confirmation of Mr. Trump's nominees to the Supreme Court and top jobs in his administration. What was once considered Congress's Job No. 1 is being eclipsed for some lawmakers by more immediate matters.
Insurers say Republicans' mixed messages and slowing pace could send premiums soaring next year while making the market much less stable. The deadline to file rates for 2018 is this spring, and insurers say they need time to decide what kinds of plans to offer and to set prices.
''We need stability and predictability,'' said Marilyn B. Tavenner, the chief executive of America's Health Insurance Plans, the main lobby for the industry.
Unless Congress continues cost-sharing subsidies, to reduce out-of-pocket costs for low-income people, and a reinsurance program, to help pay large claims, she said, more insurers will pull out of the market.
Insurers are also concerned about signs that the Trump administration may not enforce the so-called individual mandate, which requires people to have insurance or face a tax penalty. The penalty, or some way to encourage more participation, is seen as central to having enough young and healthy people sign up to keep premiums low.
''It's very important to indicate how they are going to stabilize the market,'' said Karen M. Ignagni, the chief executive of EmblemHealth, who was instrumental in the development of the current law.
At the very least, analysts say the uncertainty for insurers could lead to much higher rates. ''2018 is a wild card,'' said Deep Banerjee, who follows insurers for Standard & Poor's.
Many insurers could simply end up walking away, warned Sabrina Corlette, a research professor at Georgetown University who recently surveyed insurers about what they might do. ''At a certain point, you can't price high enough to account for that uncertainty,'' she said.
The end game is perhaps predictable. In the Senate, Republicans will need help from Democrats to replace the health law because they hold 52 seats but will need 60 votes. Several Republican senators, like Susan Collins of Maine and Bob Corker of Tennessee, say they will not vote to repeal the law unless they have a clear picture of what will replace it. And Democrats will not support any replacement unless Republicans scrap the idea of an outright repeal, which conservatives have been demanding for years.
''We can't repair the roof while Republicans and the president are burning the house down,'' said Senator Patty Murray, Democrat of Washington.
Republicans have many ideas about how to shore up insurance markets and lower costs. But it is highly unlikely that any of their proposals would be found by the Congressional Budget Office to insure as many people as the Affordable Care Act. Downbeat assessments from the budget office have doomed many proposals in the past, including the health care plan devised by Bill and Hillary Clinton in 1993.
Mr. Trump chose Representative Tom Price, Republican of Georgia, to be his secretary of health and human services, with the expectation that he would work closely with Republicans in Congress on the details of a replacement plan. Democrats have delayed his confirmation, and that in turn has delayed Republican efforts to devise an alternative to the health care law they detest.
Republicans on the Senate Finance Committee voted on Wednesday to recommend confirmation of Mr. Price, overriding objections by Democrats, who boycotted the proceedings.
All of that turmoil in Washington has left insurers scrambling.
''While the direction in Washington has been positive, we still need certainty about short-term fixes in order to determine the extent of our participation,'' Joseph R. Swedish, the chief executive of Anthem, one of the nation's largest insurers and a major player in the market, told investors on Wednesday.
Anthem said it expected to break even or make money selling individual coverage this year but said the market continued not to work as well as it could.
''We have weighed in considerably, and continue to do so, with all the leadership in Congress,'' Mr. Swedish said.
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URL: http://www.nytimes.com/2017/02/02/us/politics/the-campaign-to-destroy-obamacare-hits-a-wall.html
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GRAPHIC: PHOTO: Senator Lamar Alexander before a hearing on the health law. He said, ''It is more accurate to say 'repair Obamacare.''' (PHOTOGRAPH BY T.J. KIRKPATRICK FOR THE NEW YORK TIMES) (A16)
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(You're the Boss)
June 13, 2014 Friday
States Choose to Defer Employee Choice for Health Plans
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1065 words
HIGHLIGHT: Longtime backers of the Affordable Care Act said that the government was too generous in granting delays to the states.
When it set the final rules implementing small-business health insurance exchanges for next year, the federal government gave states the option of taking a one-year pass on one of the exchanges' most attractive features: the opportunity for small-business employees to choose among a variety of health plans. This week, the Department of Health and Human Services announced that 18 states would in fact defer employee choice until 2016.
The 18 states are: Alabama, Alaska, Arizona, Delaware, Illinois, Kansas, Louisiana, Maine, Michigan, Montana, New Hampshire, New Jersey, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, and West Virginia. But as many 33 small business insurance exchanges will offer employees a chance to choose among health plans in 2015.
In the most basic form of employee choice, the company picks a level of coverage, based on how much of the cost of care the employee will pay out of pocket. Employees can then choose any plan within that tier of coverage, where plans may vary by, say, doctor network or the amount of the deductible. Some consumer and small business advocates strongly support employee choice as an essential tool to give employees more control over their own coverage.
The Affordable Care Act created state-based health insurance exchanges for both the individual and small group markets. Apart from employee choice, there is little advantage for a business to buy insurance through a small-business exchange, unless it is small enough to qualify for a tax credit for purchasing insurance. The same plans are available off the exchange (along, in most places, with many other plans not offered on the exchange) at the same prices. The federal government is running the small-business marketplaces, often known as SHOP exchanges, in 32 states that declined to do it for themselves.
According to the regulations, state insurance commissioners had to convince the department that deferring employee choice "would be in the best interests of small employers and their employees and dependents." The commissioners' petitions were broadly similar, echoing, as expected, insurance carriers' concern that adverse selection and administrative challenges resulting from choice would increase health insurance premiums for small businesses both in the exchanges and outside of them. In Michigan, for example, the commissioner reported that four of the five biggest small group issuers said they would not participate in the small-business exchange if employees were granted choice.
Delaware's insurance commissioner, Karen Weldin Stewart, a Democrat, raised an interesting argument against allowing choice in the SHOP exchanges: There is nothing in it for insurance agents. "Most small employers rely heavily on agents and brokers in the decision-making process and pushing enrollment on the SHOP requires more of the agent's resources without any additional compensation," she wrote. "The burden will be amplified in an employee choice environment, where multiple options will require substantially more time to educate employees and provide ongoing support to the employer."
Longtime backers of the Affordable Care Act said that the government was too generous in granting delays to the states. "In order to be granted a delay, states needed to provide concrete evidence based on a documented assessment of the full landscape of the small group market that implementing employee choice would cause adverse selection and raise prices," said John Arensmeyer, chief executive of the liberal advocacy group Small Business Majority, in a statement. But, he added, "despite a failure to meet the standards, every state that requested a delay was granted one."
Support for choice is hardly universal among businesses. Both the U.S. Chamber of Commerce and the National Small Business Association joined an insurance industry coalition lobbying against employee choice in favor of employer choice - the employer's choice to pick a single health plan for all its employees.
The government sought to put the best face on the announcement, noting that 14 states* with federally run SHOP exchanges would offer employee choice in 2015, joining most of the state-run SHOP exchanges. The agency would not say which state-run exchanges were passing on choice for this year, because not all of those states had notified it of their decisions. (Eighteen states and Washington, D.C., are running their own SHOP exchanges.) But, it said, "in 2015, nearly two-thirds of Americans will live in states where small-business workers can choose a health plan rather than have their employer do it for them."
Strikingly, the decision to either defer or embrace employee choice largely appeared free of the overt politics surrounding the Affordable Care Act. One-third of the commissioners who sought, and received, the one-year delay were Democrats or appointed by a Democratic governor. And the commissioners who opted not to postpone choice were largely Republicans, including Georgia's Ralph Hudgens, who last year vowed that when it came to the health law, his office would do "everything in our power to be an obstructionist."
One exception was Pennsylvania insurance commissioner Michael F. Consedine, an appointee of Republican governor Tom Corbett, who used the occasion to take a swipe at the Obama administration. The opportunity to seek a delay, he wrote, is "another example of a troubling pattern from H.H.S. on implementation of the Affordable Care Act - decisions with the potential for negative impacts on consumers are handed to the states."
Though some advocacy groups have worried that delay in employee choice could be extended beyond 2015 - and some insurers argued for precisely that - the Health and Human Services Department was adamant in its final rule that deferring choice was a one-year transition policy only. "We expect that by 2016, states and issuers will be able to learn from the experiences of issuers in a wider range of SHOPs that have implemented employee choice so that any adverse selection concerns will no longer be material," the agency said. The administration reiterated that stance in its announcement on Tuesday.
*The 14 states with federally run exchanges that will offer choice in 2015 are Arkansas, Florida, Georgia, Indiana, Iowa, Missouri, Nebraska, North Dakota, Ohio, Tennessee, Texas, Virginia, Wisconsin, and Wyoming.
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December 21, 2016 Wednesday 00:00 EST
Health Exchange Enrollment Jumps, Even as G.O.P. Pledges Repeal
BYLINE: ROBERT PEAR
SECTION: US
LENGTH: 1256 words
HIGHLIGHT: The Obama administration said 6.4 million people had signed up so far for 2017 health insurance, an increase of 400,000 over a similar point last year.
Correction Appended
WASHINGTON - About 6.4 million people have signed up for health insurance next year under the Affordable Care Act, the Obama administration said Wednesday, as people rushed to purchase plans regardless of Republican promises that the law will be repealed within months.
The new sign-ups - an increase of 400,000 over a similar point last year - mean the health care coverage of millions of consumers could be imperiled by one of the first legislative actions of Donald J. Trump's presidency. Hundreds of thousands of other people who took no action will be automatically re-enrolled by the federal government in the same or similar plans, officials said, and their coverage could be threatened as well. Consumers still have until the end of January to enroll.
Sylvia Mathews Burwell, the secretary of health and human services, said the number of sign-ups was remarkable in view of "headwinds" created by premium increases for 2017 and by the uncertainty of the entire health law after Mr. Trump takes office on Jan. 20.
Americans remain divided over President Obama's most significant legislative achievement, even as 20 million people have gained coverage under the law and the percentage of those without insurance has dropped to record lows. Mr. Trump and Republican leaders of the House and the Senate have vowed to repeal the 2010 law as one of the first legislative actions of the Trump era.
To lay the political groundwork, Republicans have portrayed the law as collapsing under its own weight, unable to hold down health costs or provide the insurance choices its advocates promised.
But the 6.4 million signing up on HealthCare.gov through Monday could undermine the argument that the law is in free fall. The five states with the most people enrolling for coverage on the site through Monday were Florida, with 1.3 million plan selections, Texas (776,000), North Carolina (369,000), Georgia (352,000) and Pennsylvania (291,000). Mr. Trump carried all those states.
And the 6.4 million figure does not include data from states like New York and California that use their own digital marketplaces.
Democrats say that repealing the law will cause chaos and catastrophe, jeopardizing coverage for people who use HealthCare.gov and millions more who have been able to enroll in Medicaid. Whether those consumers like their coverage enough to fight for it and to resist Republican efforts to undo the law is unclear. But the enrollment figures will provide a rallying cry for Democrats intent on saving it.
"Enrollment is running ahead of last year," Ms. Burwell said. "Today's enrollment numbers confirm that doomsday predictions about the marketplace are wrong."
For their part, Republicans reiterated their concerns.
"This disaster of a law has led to massive premium spikes, less choice for patients and a collapse of the exchange markets, and no amount of spinning from the White House can hide this ugly reality," AshLee Strong, a spokeswoman for Speaker Paul D. Ryan of Wisconsin, said Wednesday.
The Trump team tried to allay concerns by promising a smooth transition to a new version of health care coverage, echoing congressional Republicans, who have floated the idea of quickly repealing the law and then delaying the effective date for several years as they try to agree on a different approach to the nation's health care problems.
"The enrollment numbers announced today show just how important health care coverage is to millions of Americans," said Phillip J. Blando, a spokesman for the Trump transition team. "The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act's well-documented flaws and provide consumers with stable and predictable health plan choices."
A number of Republican governors, including Vice President-elect Mike Pence of Indiana, supported the expansion of Medicaid eligibility under the Affordable Care Act, and some have expressed reservations about Republican plans to repeal that part of the law.
Some Republican senators have expressed similar reservations.
Thomas P. Miller, a health economist at the American Enterprise Institute and a harsh critic of the health law, predicted that the new numbers would have "a negligible effect" on the Trump administration and Republicans in Congress. "The Obama administration gets an A for effort in marketing puffery," he said, "but remains stuck with a C for execution."
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, was similarly unimpressed. "Initial enrollment numbers for the health law have long been flawed, as they do not account for consumers who actually follow through and pay the premiums," he said. "A closer look will be needed down the road to determine the final, real enrollment numbers."
But consumers are becoming concerned, administration officials say. Ms. Burwell said the federal call center had "heard from more than 30,000 people worrying about the future of their coverage in the wake of the election, and wondering whether they should still sign up for a 2017 plan."
The answer, she said, is a definite yes.
Some people might have been rushing to sign up because they were concerned about losing coverage they had gained under the health law, acknowledged Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services. A larger factor, he said, is that people need coverage and are finding it affordable.
Most consumers shopping in the public marketplace can find coverage for less than $75 a month after receiving subsidies, the administration said. But to find such bargains, consumers may have to switch plans and change doctors, officials said.
Last Thursday alone, Ms. Burwell said, 670,000 people enrolled, setting a record.
Monday was the deadline for people to sign up for coverage starting Jan. 1. The open enrollment period, which began on Nov. 1, ends on Jan. 31, 11 days after Mr. Trump takes office.
The Obama administration predicted in October that 13.8 million people would sign up for coverage or be automatically re-enrolled through the federal and state marketplaces by the end of January, and Ms. Burwell said Wednesday that she stood by that prediction.
In the past week, Obama administration officials have tried to lock in place their health policies by issuing a batch of final rules before Mr. Trump takes office.
One rule, the annual "notice of benefit and payment parameters," includes detailed standards for plan benefits, eligibility and enrollment under the Affordable Care Act. Most of the new standards apply to insurance sold in 2018. Some apply to 2019, a sign that the administration hopes the law will still be in place well into the Trump administration.
Correction: December 28, 2016, Wednesday
Because of an editing error, an article on Thursday about sign-ups for insurance under the Affordable Care Act referred incorrectly to a letter obtained by Politico and addressed to Republicans in Congress. Gov. Susana Martinez of New Mexico did not authorize or send the letter, which was drafted for her consideration by the staff of the state's health insurance exchange, an independent public corporation.
PHOTO: Signing up for health insurance in Miami last month. Enrollments have increased by 400,000 over a similar point last year. (PHOTOGRAPH BY ANGEL VALENTIN FOR THE NEW YORK TIMES) (A18)
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G.O.P. Plans to Replace Health Care Law With 'Universal Access'
Cures Act Gains Bipartisan Support That Eluded Obama Health Law
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September 4, 2012 Tuesday
Anti-Abortion, Pro-Democrat
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 488 words
HIGHLIGHT: At a Democrats for Life of America event, Bart Stupak, Kathy Dahlkemper and others defended health care reform on pro-life grounds.
CHARLOTTE, N.C.--The big question heading into the Democratic Convention is just how forcefully the party will defend the Affordable Care Act, which the president fought to pass and then declined to sell. On Tuesday, an unusually vocal endorsement of the law came from an unlikely source: Anti-abortion Democrats.
Down the road from the protesters holding up gruesome images of aborted fetuses, Democrats for Life of America held a panel discussion on why a traditionally pro-choice party should embrace a "whole life agenda." The pitch: Democrats can't achieve a majority in Congress without running candidates who oppose abortion. Two former members of the House, Bart Stupak and Kathy Dahlkemper, insisted that pro-choice Democrats could not win back their old seats.
Mr. Stupak, Ms. Dahlkemper and the other panelists admitted that the Democratic leadership did not exactly welcome their opinions. Yet despite this complaint they're not about to defect for the G.O.P. In explaining why they remain loyal they did what many in their party refuse to do: They praised the A.C.A.
Ms. Dahlkemper, who lost her Pennsylvania seat in the 2010 wave election, explained her A.CA. vote from an anti-abortion perspective.
"Abortion will only be solved when we come together to support" mothers leading up to pregnancy as well as after. "Both mother and baby need access to affordable health care." Mothers also need "to know that there's a social safety net."
More soft-spoken than Barney Frank, she seemed to allude to his quip that Republicans think "life begins in conception and ends at birth" when she said that many on the right "claim to be pro-life yet lack commitment to social justice issues" and refuse to support programs that help mothers access medical care.
Thomas Berg, from the University of St. Thomas, said the Republicans' determination to repeal the A.C.A. would only hinder the anti-abortion cause. He argued that Mitt Romney's Massachusetts health care law has driven down the abortion rate among teenagers, and he suggested that the A.C.A. will do the same. The A.C.A. includes "a number of pro-life benefits" such as funds to assist pregnant students on college campuses.
During the question and answer session, a reporter from RedState.com asked the panelists how they could support President Obama, who, she said, favors "infanticide." Everyone on stage looked a little embarrassed.
By way of an answer, Stephen Schneck from The Catholic University of America told the audience that Mr. Romney proposes to slash Medicaid--which pays for more than one-third of all births in the United States. Births are expensive, whereas abortion costs almost nothing, suggesting that abortions would "skyrocket" if Mr. Romney came to power by as much as 6 or even 8 percent.
Tell Me Something New
The President Fumbles the Court Issue
President Obama Takes Action on Vets' Mental Health
Mitt Romney Is Disappointed
The Moderate Fringe
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March 17, 2015 Tuesday
Late Edition - Final
Data on Health Law Shows Largest Drop in Uninsured in 4 Decades, the U.S. Says
BYLINE: By ROBERT PEAR; Julie Hirschfeld Davis contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 720 words
WASHINGTON -- The Obama administration said on Monday that 16.4 million uninsured people had gained health coverage since major provisions of the Affordable Care Act began to take effect in 2010, driving the largest reduction in the number of uninsured in about 40 years.
Since the first open enrollment period began in October 2013, the officials said, the proportion of adults lacking insurance has dropped to 13.2 percent, from 20.3 percent.
Sylvia Mathews Burwell, the secretary of health and human services, said the data revealed ''the largest reduction in the uninsured in four decades.'' Many people gained coverage after the creation of Medicare and Medicaid in 1965.
White House officials said the figures disproved the charges leveled by some Republicans opposed to the law, including governors who have declined to expand their Medicaid programs.
''We've seen tens of millions, if not hundreds of millions, of dollars being spent by the president's political opponents to distort the facts about the true impact of the Affordable Care Act,'' Josh Earnest, the White House press secretary, said on Monday. ''We're very pleased about the impact that this has had in expanding coverage for more Americans.''
Polls show that public opinion on the health care law is still deeply divided, and its future could be an issue in next year's elections. Richard G. Frank, an assistant secretary of health and human services, said the new data showed that ''the Affordable Care Act is working.''
Officials said they were publishing the figures to demonstrate its progress on the fifth anniversary of the law, which President Obama signed on March 23, 2010.
Since October 2013, Mr. Frank said, 14.1 million uninsured people ages 18 to 64 have gained insurance. In addition, he said, 2.3 million young adults were covered from 2010 to October 2013 because they were allowed to remain on their parents' health plans until the age of 26 under a provision of the law.
Federal officials said they did not know how many of the 14.1 million newly insured Americans had gained private coverage through health insurance exchanges and how many had obtained their coverage through Medicaid. Many states say their Medicaid enrollment numbers are larger.
Senator John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, said: ''Millions of people have lost coverage they liked, and out-of-pocket costs continue to rise. Coverage does not equal care.''
Moreover, he said, the addition of people to the Medicaid rolls is ''hardly worth celebrating.''
Mr. Frank said the estimates were obtained by applying a statistical model to data from a large private survey conducted for the Gallup-Healthways Well-Being Index. He predicted that the estimates would be confirmed in surveys conducted by the Census Bureau and the Centers for Disease Control and Prevention.
The administration's estimates were similar to those of the Congressional Budget Office. In a report last week, the budget office said that the health care law had reduced the number of uninsured people under the age of 65 by 17 million, to a total of 35 million people.
Joseph R. Antos, an economist at the American Enterprise Institute, a right-of-center think tank, said it was not possible to say how much of the reduction in the uninsured resulted from improvements in the economy and how much was attributable to the Affordable Care Act.
All the changes were measured against levels of insurance coverage in the 21-month period from January 2012 to September 2013, just before the beginning of open enrollment under the health law.
For decades, the proportion of blacks who are uninsured has been higher than the proportion for the nation as a whole. If the Obama administration is correct, that gap may be disappearing.
The administration estimated that 2.3 million black adults had gained coverage since October 2013, lowering the proportion who are uninsured to 13.2 percent, the same as the average for all adults.
Federal officials said that 6.6 million non-Hispanic white adults and 4.2 million Latino adults had also gained coverage. The proportion of Latinos who were uninsured dropped to 29.5 percent, from 41.8 percent, the administration said, and the proportion for whites declined to 9 percent, from 14.3 percent.
URL: http://www.nytimes.com/2015/03/17/us/data-on-health-law-shows-largest-drop-in-uninsured-in-4-decades-the-us-says.html
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November 25, 2013 Monday
The Health Care 'Distraction' Conspiracy
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 289 words
HIGHLIGHT: Senator John Cornyn said the deal with Iran was an attempt to distract attention from the Affordable Care Act.
Two things happened last week that had nothing to do with the Affordable Care Act. This, Republicans say, is proof of a devious Democratic conspiracy to distract the American people from the Affordable Care Act.
On Thursday, Democrats in the Senate voted to curb use of the filibuster on executive and judicial appointments. The Times editorial said the change was long overdue "given the extreme degree of Republican obstruction during the Obama administration." (Republicans have blocked a record number of executive-branch nominees in the last five years.) But the Senate minority leader, Mitch McConnell, said the vote had nothing to do with Republican tactics, and everything to do with health insurance.
"Just yesterday, I saw a story about a guy getting a letter in the mail saying his dog, his dog had qualified for insurance under Obamacare," Mr. McConnell said on the Senate. "So yeah, I would probably be running for the exit, too, if I had supported this law. I would be looking to change the subject, change the subject just as Senate Democrats have been doing with their threats of going nuclear and changing the Senate rules on nominations."
Senator John Thune, Republican of South Dakota, agreed, telling Breitbart News that Democrats were trying to divert attention from "all of their broken ObamaCare promises."
Then on Saturday, Iran agreed to a temporary freeze of its nuclear program. News outlets around the world covered the historic diplomatic breakthrough-which raised Senator John Cornyn's suspicions.
"Amazing what WH will do to distract attention from O-care," the Texas Republican wrote on Twitter.
If he was joking, he never gave himself away. Later he tweeted, "Isn't it true that WH are masters of distraction?"
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The New York Times
January 4, 2017 Wednesday 00:00 EST
Senate Republicans Open Fight Over Obama Health Law
BYLINE: THOMAS KAPLAN and GLENN THRUSH
SECTION: US; politics
LENGTH: 1233 words
HIGHLIGHT: President Obama made a rare trip to Capitol Hill to defend the Affordable Care Act, as the Republican-led Congress took the first step toward undoing significant parts of it.
WASHINGTON - Congress opened for battle over the Affordable Care Act on Wednesday as Republicans pushed immediately forward to repeal the health care law and President Obama made a rare trip to Capitol Hill to defend it.
The bitterness that has long marked the fight intensified as Republicans seized the opportunity to make good on a central campaign promise to get rid of the law, a pledge reinforced on Wednesday by Vice President-elect Mike Pence, who met with House Republicans not far from where the president gathered with Democrats.
The Affordable Care Act, Mr. Obama's signature health care law, has created online insurance marketplaces, offered new protections to people seeking health insurance, and provided coverage to millions of people near the poverty line through expanded Medicaid. Health policy experts say that system could collapse if Republicans cut off funds for the expanded coverage and end penalties for people who go without health insurance.
"The American people voted decisively for a better future for health care in this country," Mr. Pence said, "and we are determined to give them that." He said that President-elect Donald J. Trump would use his executive authority to help make the transition away from the health care law, but did not offer specifics.
Democrats vowed aggressive resistance, however, and said they would not participate in drawing up a replacement for the law after the swift efforts to unravel it. Senator Chuck Schumer of New York, the new Democratic leader, playing off Mr. Trump's campaign slogan, said repealing the law would "make America sick again."
Republicans are using a procedural approach that will allow them to repeal substantial parts of the health care law without Democrats' being able to mount a filibuster in the Senate.
By a vote of 51 to 48 on Wednesday, the Senate took the first step, agreeing to take up a budget resolution, or blueprint, that would clear the way for legislation repealing major provisions of the law. But even as Republicans spoke of moving quickly to repeal the law, it remained far less clear how and when they would go about replacing it.
Senate debate on the budget resolution is expected to continue for several days, and the House plans to take up the measure once the Senate has approved it.
As Republicans charged ahead, both sides seemed cognizant of the possible fallout from unwinding the law, which has become deeply enmeshed with America's health care system and has provided insurance for about 20 million people.
Mr. Trump weighed in with several Twitter posts. He advised that Republicans needed to "be careful in that the Dems own the failed Obamacare disaster," and added, "Don't let the Schumer clowns out of this web."
Mr. Trump predicted that the health care law would "fall of its own weight."
Representative Chris Collins of New York, a Republican who is one of Mr. Trump's top supporters in Congress and is part of his transition team, said it was important to be sure that Democrats bear responsibility for the failings of the health care law. Republicans point out that premiums have risen and that consumers in many places have fewer choices of insurers.
"We have to make sure we keep reminding America, we are repealing it because it failed, we are repealing it because they all but demanded that we repeal it," Mr. Collins said. "And that was a key piece of Donald Trump's campaign."
But as Republicans expressed eagerness to repeal the law, they acknowledged that replacing it would take more time. It is also unclear how insurance companies will react during this period and whether they will continue to offer the marketplace plans that millions of people have come to rely on.
"There will naturally be a reasonable transition period," said Senator Ted Cruz, Republican of Texas. "You can't adopt new reforms all at once."
Senator John Cornyn of Texas, the No. 2 Senate Republican, noted that it had taken six years to get into "the ditch we find ourselves in now."
"When your truck or car is in a ditch, the first thing you need to do is get out of the ditch," Mr. Cornyn said. "And sometimes that takes a lot of hard work."
To that, Senator Debbie Stabenow, Democrat of Michigan, parried that when a car goes into a ditch, "the first thing I don't do is dismantle the car."
"That doesn't help me get anywhere in terms of transportation," she said.
Democrats signaled little interest in helping Republicans determine what to do after repealing major parts of the health care law.
Mr. Schumer predicted that in a year, Republicans would "regret that they came out so fast out of the box." He said Democrats would consider working on a replacement only after Republicans presented their own plan.
"If you are repealing, show us what you'll replace it with first," Mr. Schumer said. "Then we'll look at what you have and see what we can do."
Later, Mr. Schumer said of Mr. Trump, "It's his and their responsibility, plain and simple - name calling isn't going to get anything done." He added, "They really need to calm things down a little."
Speaker Paul D. Ryan tried to offer assurance that no change in coverage would be abrupt.
"The point is, in 2017, we don't want people to be caught with nothing," he said. "We want to make sure that there's an orderly transition so that the rug is not pulled out from under the families who are currently struggling under Obamacare while we bring relief."
Mr. Obama huddled with congressional Democrats for about 90 minutes in what was billed by the White House as a strategy session to forge a unified Democratic response to the Republicans' rollback effort.
In reality, the session was essentially a going-away party for a man who passed his signature legislative accomplishment under long-extinct majorities in Congress and a "pep rally" for Affordable Care Act defenders, in the words of an attendee, Representative Hank Johnson, Democrat of Georgia.
The gathering, which could be Mr. Obama's last trip to the halls of Congress that have been the site of alternating triumph and defeat, had a two-weeks-before-graduation air, with numerous Democratic lawmakers, including Mr. Johnson, sneaking out to attend to business more pressing than hearing the president's words.
Mr. Obama, for his part, did not ask his allies to block all efforts to alter the law, but warned Democrats against "rescuing" Republicans by defecting on votes that would dismantle it.
The president provided an array of arguments for keeping the Affordable Care Act and offered a mild mea culpa for his shortcomings as a salesman over the years.
Senator Jeff Merkley, Democrat of Oregon, said, "He acknowledged the failures in selling the law in its entirety to the American people."
Robert Pear and Emmarie Huetteman contributed reporting.
PHOTOS: Top, President Obama on Capitol Hill on Wednesday before meeting with Democrats. Above, Vice President-elect Mike Pence with Speaker Paul D. Ryan after a Republican caucus. (PHOTOGRAPHS BY AL DRAGO/THE NEW YORK TIMES; DOUG MILLS/THE NEW YORK TIMES) (A1); The Capitol on Wednesday. Inside, the Republican-led Congress began taking steps to roll back the Affordable Care Act. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A12)
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March 11, 2017 Saturday
Late Edition - Final
Wealthy Would Get Big Tax Cut Under Affordable Care Act Repeal Plan
BYLINE: By JESSE DRUCKER
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LENGTH: 594 words
Two of the biggest tax cuts in Republican proposals to repeal the Affordable Care Act would deliver roughly $144 billion over the coming decade to those with incomes of $1 million or more, according to a congressional analysis.
The assessment was made by the Joint Committee on Taxation, a nonpartisan panel that provides research on tax issues.
It is not unusual for tax cuts to benefit mostly the wealthiest, but still save some money for a majority of Americans. But the benefits of these reductions would be aimed squarely at the top.
The provisions would repeal two tax increases on high earners enacted in 2010 to help pay for the Affordable Care Act: an increase in capital gains taxes and other investment-related income, and a surcharge on Medicare taxes.
People making $200,000 to $999,999 a year would also get sizable tax cuts. In total, the two provisions would cut taxes by about $274 billion during the coming decade, virtually all of it for people making at least $200,000, according to a separate assessment by the committee.
''Repeal-and-replace is a gigantic transfer of wealth from the lowest-income Americans to the highest-income Americans,'' said Edward D. Kleinbard, a professor at the University of Southern California law school and former chief of staff for the Joint Committee on Taxation.
Tax economists point out that even tax cuts for the wealthy can have indirect benefits for others. For example, the additional cash can prompt extra spending and extra hiring.
That said, ''most of the benefit of getting rid of those two taxes would go to wealthy people,'' said Joel Slemrod, a professor at the University of Michigan Ross School of Business and former senior staff economist for President Ronald Reagan's Council of Economic Advisers. ''It's not significant for me to add a caveat.''
One of the taxes targeted in the repeal bill is a 3.8 percent tax on investment income, like capital gains. The other is a 0.9 percent surcharge on the Medicare taxes imposed on high-income earners -- individuals making more than $200,000 a year and married couples filing joint returns who earn more than $250,000 a year. That brings the Medicare tax levied on that income up to 3.8 percent as well.
The tax repeal would solely benefit wealthy Americans because the taxes were imposed only on the wealthiest. The increases were passed in 2010, when capital gains rates were near historical lows. During the George W. Bush administration, Congress cut the rates to 15 percent from 20 percent. With the 3.8 percent tax imposed by the Affordable Care Act, the top capital gains rate stands at 23.8 percent for the wealthiest Americans. That still makes the rate lower than it was for most of the 1970s, 1980s and 1990s.
The panel's analysis was provided to members of the House Ways and Means Committee on Wednesday but has not been published on the committee's website. A copy was reviewed by The New York Times.
The analysis found that by 2020, the repeal of the two tax provisions would save about $15.9 billion a year for those with incomes of $1 million or more. By 2026, the final year of the analysis, they would combine to save that group a little more than $20 billion a year.
For all the taxpayers who would benefit, the tax cuts would save nearly $37 billion in a single year by 2026.
On Monday, the Congressional Budget Office is expected to issue its analysis of the total cost of the Republican plan to replace the Affordable Care Act, including how much, if anything, it would add to the federal deficit in the coming decade.
URL: http://www.nytimes.com/2017/03/10/business/tax-cuts-affordable-care-act-repeal.html
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March 6, 2017 Monday
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Repeal of Health Law Hits a New Snag: Older Adults
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 865 words
WASHINGTON -- Republican plans to repeal the Affordable Care Act have encountered a new obstacle: adamant opposition from many older Americans whose health insurance premiums would increase.
AARP and its allies are bombarding congressional offices with objections as two House committees plan to vote on the Republicans' bill this week.
If the law is repealed, the groups say, people in their 50s and 60s could see premiums rise by $2,000 to $3,000 a year or more: increases of 20 percent to 25 percent or higher.
Under current rules, insurers cannot charge older adults more than three times what they charge young adults for the same coverage. House Republican leaders would allow a ratio of five to one -- or more, if states choose.
Insurers support the change, saying it would help them attract larger numbers of young customers.
The current rating restrictions, they say, have increased premiums for young adults, discouraging them from enrolling.
But the Republican proposal would ''increase the financial burden of older Americans, making coverage significantly less affordable,'' says a letter to Congress from the Leadership Council of Aging Organizations, a coalition of nonprofit groups that represent the interests of older Americans.
The letter was addressed to Representative Greg Walden, Republican of Oregon and the chairman of the Energy and Commerce Committee, one of two House panels planning to vote this week on a bill that would roll back major provisions of President Barack Obama's signature domestic accomplishment.
David M. Certner, the legislative policy director of AARP, said the proposal would have ''a severe impact on Americans age 50 to 64 who have not yet become eligible for Medicare.''
At the same time, Mr. Certner said, the Republican proposal could reduce the financial assistance available to help people pay insurance premiums.
Republicans say their proposal would reduce insurance prices by stimulating competition and by allowing insurers to sell a leaner, less expensive package of benefits.
In Mr. Walden's hometown, Hood River, Ore., for example, the average premium for a midlevel silver plan for a 60-year-old man is $10,500 a year, compared with $3,864 for a 21-year-old man, according to HealthCare.gov, the online federal insurance marketplace.
Many people who buy insurance through the exchanges qualify for subsidies to help defray the cost. But people who buy insurance outside the Affordable Care Act marketplace cannot obtain subsidies.
Republicans in the House and the Senate want to change that, so people can get subsidies in the free market outside the public exchange.
Before the Affordable Care Act took effect, about 40 states allowed insurers to charge older adults five times as much as young adults. This appears to be consistent with patterns of medical spending.
''Average spending among people who are 64 years old is about 4.8 times as high as average spending among people who are 21 years old,'' the Congressional Budget Office said last year, citing research by actuaries.
Representative Larry Bucshon, Republican of Indiana and a heart surgeon, said the rating restrictions in the 2010 health law had ''led to sicker insurance pools and driven younger, healthier patients away from the marketplace.''
''The argument that the three-to-one ratio saves seniors money may not be true,'' Mr. Bucshon said. ''In fact, I don't think it is true. It has just increased costs for younger people.''
Republicans contend that benefit mandates in the health law have driven up insurance costs. The House Republican bill would allow states to define the ''essential health benefits'' that insurers must provide.
Jerry C. Fleming, a retired health insurance executive who worked at Kaiser Permanente for more than 35 years, said on Sunday that the House Republican plan could produce ''breathtaking increases in premiums'' for older people with low incomes.
Their share of the premium could, in some cases, more than double, he said.
Another provision of the bill drafted by House Republican leaders has come under fire in recent days.
The bill says that, in providing financial assistance to help people buy insurance, federal officials will verify eligibility using the same ''methods and procedures'' used by the Obama administration under the Affordable Care Act.
Republicans have repeatedly criticized those procedures as inadequate, saying they verify citizenship but not a person's identity.
The Government Accountability Office, an investigative arm of Congress, has found the marketplaces ''vulnerable to fraud'' because they do not adequately check the identity of people applying for financial assistance.
In 2010, just before Congress gave final approval to the Affordable Care Act, the conservative House Republican Study Committee said the verification procedures in the bill were ''insufficient and ineffective.''
The study committee was headed then by Representative Tom Price, Republican of Georgia, who was sworn in last month as President Trump's secretary of health and human services.
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URL: http://www.nytimes.com/2017/03/05/us/politics/health-care-law-obamacare-repeal-older-americans.html
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March 26, 2015 Thursday
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Obama Praises Affordable Care Act on Its 5th Birthday
BYLINE: By MICHAEL D. SHEAR
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WASHINGTON -- President Obama marked the fifth anniversary of the Affordable Care Act by mocking the law's longtime critics as wrong about their predictions that its passage would doom America's health care system.
In an event at the White House on Wednesday, Mr. Obama said the law had decreased the ranks of the uninsured by a third, having enabled 16 million people to sign up for health coverage through the government marketplaces.
''We have been promised a lot of things in these past five years that didn't turn out to be the case,'' Mr. Obama said. ''Death panels, doom, a serious alternative from Republicans in Congress.''
The president's remarks came as the law remained under attack on multiple fronts. In a challenge before the Supreme Court this month, plaintiffs argued that a critical part of the law -- the subsidies that make insurance affordable -- cannot be provided to people signing up at HealthCare.gov.
And Republicans, who now control Congress, are pressing forward with efforts to change or even repeal parts of the law. In announcing his candidacy for president on Monday, Senator Ted Cruz, Republican of Texas, vowed to repeal ''every single word'' of the health care law.
Michael C. Short, a spokesman for the Republican National Committee, issued a statement shortly after Mr. Obama's remarks.
''No matter how much President Obama spins his unpopular health care law so Hillary Clinton can run for his third term, middle class Americans are still being saddled with higher premiums, higher taxes, fewer work hours, and canceled plans,'' Mr. Short said.
For Mr. Obama, the attacks may become easier to deflect, given the statistics that he cited at the event on Wednesday. He said that health care premiums would be $1,800 higher now if price growth in that industry had continued at the rate of five years ago. He said that cuts in Medicare drug costs had saved seniors $15 billion.
''It's working, despite countless attempts to repeal, undermine, defund and defame this law,'' Mr. Obama said.
''It's not the job killer that critics have warned about for five years,'' Mr. Obama said. ''When this law was passed, our businesses began the longest streak of private sector job growth on record. Sixty straight months. Five straight years. Twelve million new jobs.''
Republicans insist that the economy would have been even better without the health care law. But after years in which the White House was on the defensive -- especially when it came to the rocky implementation of the law -- Mr. Obama on Wednesday was ready to simply brag about it.
''We know beyond a shred of a doubt that the policy works,'' he said.
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November 5, 2013 Tuesday
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Obama to Campaign to Ensure Health Law's Success
BYLINE: By JACKIE CALMES
SECTION: Section ; Column 0; National Desk; Pg.
LENGTH: 511 words
WASHINGTON -- On the fifth anniversary of his election, President Obama told a rally of grass-roots supporters on Monday evening that ''I've got one more campaign in me'' -- to make sure his signature health care law works.
The president, who has faced four years of Republican attacks against the law in Congress, state capitals and the Supreme Court, sought to reassure about 200 leaders of his Organizing for Action network at its health care summit meeting. His comments followed a month of controversy since the law's health insurance exchanges opened, including the program's malfunctioning website and complaints about canceled policies.
''When the unexpected happens, when the unanticipated happens, you know, we're just going to work on it. We're going to fix things that aren't working the way they should be, and we're going to smooth this thing out,'' Mr. Obama told his mostly young supporters at the St. Regis Hotel near the White House.
Organizing for Action, which grew out of Mr. Obama's election campaign network, is dedicated to helping build support for his governing agenda. With the president on the defensive over the Affordable Care Act, the White House was eager for the group's help in getting out the word on the president's commitment to fix the healthcare.gov website. The site's problems have prevented untold numbers of Americans, mainly those without employer-provided group health insurance, from enrolling for individual coverage in the new, state-based marketplaces or exchanges. Mr. Obama urged the group's members to spread any success stories ''far and wide.''
''Every day there are new stories to tell,'' he said, recounting a letter he received from a Lexington, Ky., man who wrote that his household of six had found a better policy at half the price of his $1,500-a-month plan, and with a deductible of $500 instead of $3,000.
Mr. Obama has been widely criticized for having promised as a presidential candidate that Americans could keep their current coverage under his insurance program, and on Monday he modified his language in the face of reports, long anticipated, that some companies had canceled individual policies because they did not meet minimum coverage standards set by the Affordable Care Act.
''If you have or had one of these plans before the Affordable Care Act came into law, and you really liked that plan, what we said was you can keep it if it hasn't changed since the law was passed,'' Mr. Obama said.
Below-standard policies have to change, but the president said that was in keeping with his promise of high-quality coverage that was affordable.
''Because of the competition between insurers and the new health care tax credits, most people will be able to buy better plans for the same price or even cheaper than what they got before,'' Mr. Obama said. ''Now some Americans with higher incomes will pay more up front, for better insurance with better benefits and better protections that could eventually help them a lot.''
But ''nobody can be dropped all together,'' he said, adding, ''Those days are over.''
URL: http://www.nytimes.com/2013/11/05/us/politics/obama-to-campaign-to-ensure-health-laws-success.html
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February 1, 2016 Monday
Voter Who Confronted Ted Cruz on Obamacare Said He's Surprised by the Attention
BYLINE: STEVE EDER
SECTION: US; politics
LENGTH: 648 words
HIGHLIGHT: A Hillary Clinton supporter whose brother-in-law died shortly after he gained coverage under the Affordable Care Act said he got the idea to confront Senator Ted Cruz after hearing him speak in the fall.
Last fall, Mike Valde attended a Ted Cruz speech, where the Texas senator delivered his standard presidential promise to repeal President Obama's signature health care law.
As he sat in the audience, Mr. Valde, 63, of Coralville, Iowa, thought of his brother-in-law, Mark Gaffney, who had recently died but had also used the law to buy insurance. Mr. Valde said he began to wonder how Mr. Cruz would replace the Affordable Care Act - and how it would impact people like Mr. Gaffney.
"After I saw him there, I didn't say a word. I wished I had asked him something," Mr. Valde, a supporter of Hillary Clinton, recalled in a phone interview Sunday. "Why didn't I speak up and say, 'How do you take care of the Mark Gaffneys of the world?'"
So, on Saturday, Mr. Valde got his chance - and took it - during an intense exchange with Mr. Cruz in a middle school cafeteria in Hubbard, Iowa. Mr. Valde described how Mr. Gaffney, a barber in Arizona, worked for himself and never had a paid vacation day, and used the health care law, at last, to buy insurance. He began feeling ill and went to a doctor, and soon learned he had terminal cancer, Mr. Valde told Mr. Cruz. The room went silent.
"Mark never had health care until Obamacare," Mr. Valde told Mr. Cruz, "What are you going to replace it with?"
Mr. Cruz, during a back-and-forth, expressed condolences, while also deriding the law as a job-killer that has made insurance premiums "skyrocket."
The exchange became a highly discussed moment on the campaign trail during the final days before the Iowa caucuses. Later Saturday, Mrs. Clinton mentioned it during a rally at a high school, criticizing how Mr. Cruz does not offer an alternative to the health care law.
Mr. Valde and his wife, Jill, Mr. Gaffney's sister, attended a Bill Clinton rally on Sunday and chatted with Mr. Clinton in the rope line, with the former president telling them he had heard about the question posed to Mr. Cruz.
The Valdes said they were surprised by the attention, with word of the exchange getting back to Mr. Gaffney's friends hundreds of miles away. "When Mark's friends saw it in Arizona, they said, 'Thanks for bringing it up,'" Mrs. Valde said.
Republicans in Congress have repeatedly tried to repeal the health care law, which they see as an expensive government program, but President Obama has vetoed their attempts. The law is unpopular in public opinion polls, and Mr. Cruz and virtually all the other Republican candidates have vowed to get rid of it if elected.
Mr. and Mrs. Valde said in the interview that before the Affordable Care Act, Mr. Gaffney had either been uninsured or lightly insured, making it prohibitively expensive for him to see doctors.
"He was having financial problems and the last thing he could do was pay to take care of himself," Mrs. Valde said. "He'd say: 'It's just too expensive. I can't afford to go.'"
When coverage under the health care law went into effect in 2014, Mrs. Valde said she suggested to her brother that he should sign up, and he eventually did, though she did not know precisely when.
It was last spring when they visited him that they noticed that he appeared unwell, and they encouraged him to see a doctor. By summer, he told them that he had terminal cancer, and he died on Aug. 16 at age 58.
The Valdes said that they did not believe that earlier access to the health insurance necessarily would have saved Mr. Gaffney's life, but that his plight convinced them that the access to coverage he ultimately obtained would be important for others. They were grateful, they said, that Mr. Gaffney was eventually able to see a doctor.
"What about people like him? Mr. Valde said. "People could be saved."
He added, "There are a lot of Mark Gaffneys out there."
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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October 23, 2013 Wednesday
Sebelius Finds a Friendly Crowd in Boston
BYLINE: Jess Bidgood
SECTION: US
LENGTH: 458 words
HIGHLIGHT: For Kathleen Sebelius, the health and human services secretary, a gala in Boston appeared to be a much-needed respite from scrutiny and criticism over the bungled rollout of the online health insurance exchanges.
BOSTON - For Kathleen Sebelius, the Obama administration official who has become the focus of bipartisan anger over the bungled rollout of the online health insurance exchanges, a night out in Boston appeared to be a much-needed respite from scrutiny and criticism.
"What a great room to be in, for all kinds of reasons," Ms. Sebelius, the secretary of health and human services, told an audience of about 400 people on Wednesday at the Kennedy Forum on Community Mental Health.
"I can tell you it's good for my mental health," she said, as the crowd laughed.
Ms. Sebelius has faced repeated calls to resign over the problems with the health care law's insurance exchanges, which could take months to fix. She did not address those issues in detail, although she did echo a point President Obama made earlier in the week.
"The new law is more than a Web site," she said. "It is an opportunity for millions of Americans to obtain mental health and physical health services."
The gala Wednesday night kicked off a conference on mental health that will be hosted Thursday by the Kennedy Forum, led by former Representative Patrick J. Kennedy of Rhode Island. The event is a celebration of the Community Mental Health Act, which Mr. Kennedy's uncle, President John F. Kennedy, signed 50 years ago.
In introducing Ms. Sebelius, Mr. Kennedy told the audience, "We must stand firmly with Secretary Sebelius so she can stand up for us."
In her own remarks, Ms. Sebelius highlighted the aspects of the law that she said would increase Americans' access to mental health care and expand coverage of preventive mental health services.
When Vice President Joseph R. Biden Jr. spoke, he jokingly acknowledged that the gathering was competing with the World Series opening game nearby between the Boston Red Sox and the St. Louis Cardinals. "I'll give you a moment to get your earpieces out and tune in to the game," he said. "I am not at all offended."
Like Ms. Sebelius, Mr. Biden - who did not directly address the problem-plagued exchanges - focused on the Obama administration's efforts to promote mental health, including through the Affordable Care Act, which he said would allow more Americans to take advantage of mental health care.
"We made sure the Affordable Care Act includes mental health and substance abuse services as one of the 10 categories of essential benefits that must be covered by health plans in new health marketplaces," he said.
Readers Ask About Subsidies and Other Health Care Law Provisions
Tea Party Group Begins Anti-Health Care Law Blitz in Four House Districts
Awareness Grows of Online Insurance Exchanges, and Their Problems, Survey Finds
Readers Ask How Insurance Subsidies Are Calculated for Students
A Closer Look at the Reinsurance Fee
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February 13, 2017 Monday
Late Edition - Final
G.O.P., Aiming to Kill Health Law, Also Works to Shore Up Its Exchanges
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 9
LENGTH: 1126 words
WASHINGTON -- After denouncing the Affordable Care Act as an abomination for seven years, Republicans in Congress, working with the Trump administration, are urgently seeking ways to shore up health insurance marketplaces created by the law.
While President Trump said as a candidate that ''Obamacare is certain to collapse of its own weight,'' Republicans fear such an outcome because, now that the fate of the health law is in their hands, they could be blamed by consumers and Democrats.
The administration is poised to issue a proposed regulation to try to stabilize insurance markets, and House Republicans are drafting legislation with a similar purpose. The regulation and the bills are intended to hold down insurance premiums and to lure insurers back into the public marketplaces from which they have withdrawn in the past couple of years.
The Republican proposals address concerns that insurers have been expressing for several years, among them what they call costly abuse of special enrollment periods. But markets could still be undermined, insurers say, if Congress simultaneously repeals the health law's requirement for most Americans to have coverage.
That requirement, known as the individual mandate, is one of the more unpopular features of the law, signed in 2010 by President Barack Obama. But insurance companies like it because it requires people to buy their product, bringing in healthy people who pay premiums and do not use much care.
Analyzing the Republican strategy, Joel L. Michaels, a health lawyer at the firm McDermott Will & Emery, said there was ''a tension'' between efforts to repeal the health law and shore up its insurance marketplaces, where more than 10 million people obtained coverage last year.
''A political agenda premised on the Affordable Care Act being unworkable could conflict with efforts to support the A.C.A. exchanges, even on an interim basis,'' Mr. Michaels said. ''How far do you go with short-term fixes, which could make the law work better in the long term? It's a delicate political dance.''
Insurers are seeking immediate governmental action because they must decide by early May what kinds of health plans they will offer on the exchanges in 2018.
The proposed rule drafted by the Trump administration and one of the bills drafted by House Republicans would make it more difficult for consumers to obtain insurance outside the annual open enrollment period. Consumers would have to provide documents to show they were eligible for a special enrollment period. Under existing rules, people can sign up after the deadline if they experience certain ''life changes'' like having a baby, getting married, losing employer-sponsored insurance or moving to a new state.
But insurers say that some consumers have misused these special enrollment periods, signing up when they became sick and dropping coverage after they received the care they needed.
Insurers say people who sign up in a special enrollment period use up to 50 percent more services than those who sign up in the standard enrollment season.
In documents provided to the White House at a meeting last week, Blue Cross and Blue Shield executives said federal officials should limit the number of special enrollment periods and ''require all individuals to show proof of eligibility before coverage starts'' -- an idea endorsed by several governors.
Gov. Bill Haslam of Tennessee, a Republican, said that ''special enrollment periods are an absolute necessity for individuals who experience a change in life circumstance.'' But, he said, they have been ''so broadly defined that they are almost akin to a permanent open enrollment period, allowing individuals to access health insurance benefits only when health care is an immediate necessity.''
Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said she had not seen convincing evidence of abuse.
Moreover, she said, the documentation requirements ''will decrease enrollment, for sure, and will disproportionately deter younger and healthier people'' from trying to sign up.
Under another Republican proposal, it would be easier for insurers to terminate coverage for people who fail to pay their premiums. The Affordable Care Act says insurers generally must allow a three-month grace period before ending coverage for people who receive federal subsidies to help pay premiums.
About 85 percent of people who obtain insurance through the Affordable Care Act's marketplaces receive such subsidies, and the three-month grace period is longer than that typically required by state laws.
Under a bill introduced last month by Representative Bill Flores, Republican of Texas, the federal government would recognize any grace period set by state law, and if a state did not have a law, the grace period would be one month.
Several governors, including Brian Sandoval of Nevada and Gary R. Herbert of Utah, both Republicans, endorsed this change. ''Reducing the grace period from 90 days to 30 days, which is standard industry practice for most other insurance products, would assist in stabilizing the individual market,'' Mr. Herbert said.
Republicans in Congress are also warming to the idea of continuing payments to insurance companies to help cover the out-of-pocket costs for people with low incomes.
House Republicans filed suit against the Obama administration to stop these payments, saying Congress never appropriated money for them, and a federal district judge ruled for the lawmakers in May.
The payments reimburse insurers for certain discounts they are required to provide to low-income people, and without the payments, which are expected to total $9 billion this year, insurers say they would drop out of the market or sharply increase premiums.
Representative Mark Meadows, a conservative Republican from North Carolina and a fierce critic of the health care law, said he wanted to avoid disrupting coverage for consumers while Republicans repeal the law and devise a replacement.
''As long as we have a real repeal and replacement strategy,'' Mr. Meadows said, he might accept a temporary continuation of the cost-sharing subsidies.
''I would be more flexible and could swallow some short-term heartburn for longer-term fiscal responsibility and lower health care costs for the people I represent,'' he said.
Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, said he, too, was willing to allow a ''temporary continuation of cost-sharing subsidies for deductibles and co-payments.''
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URL: http://www.nytimes.com/2017/02/12/us/politics/affordable-care-act-republicans-stability.html
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GRAPHIC: PHOTO: An Affordable Care Act mall kiosk in Miami in November. More than 10 million people obtained coverage through the law's insurance marketplaces last year. (PHOTOGRAPH BY ANGEL VALENTIN FOR THE NEW YORK TIMES)
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The New York Times
January 22, 2017 Sunday 00:00 EST
Trump's Health Plan Would Convert Medicaid to Block Grants, Aide Says
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 786 words
HIGHLIGHT: The change would be a profound one for the health insurance program for low-income people, raising a host of thorny political and financial questions.
WASHINGTON - President Trump's plan to replace the Affordable Care Act will propose giving each state a fixed amount of federal money in the form of a block grant to provide health care to low-income people on Medicaid, a top adviser to Mr. Trump said in an interview broadcast on Sunday.
The adviser, Kellyanne Conway, who is Mr. Trump's White House counselor, said that converting Medicaid to a block grant would ensure that "those who are closest to the people in need will be administering" the program.
A block grant would be a radical change. Since its creation in 1965, Medicaid has been an open-ended entitlement. If more people become eligible because of a recession, or if costs go up because of the use of expensive new medicines, states receive more federal money.
If Congress decides to create block grants for Medicaid, lawmakers will face thorny questions with huge political and financial implications: How much money will each state receive? How will the initial allotments be adjusted - for population changes, for general inflation, for increases in medical prices, for the discovery of new drugs and treatments? Will the federal government require states to cover certain populations and services? Will states receive extra money if they have not expanded Medicaid eligibility under the Affordable Care Act, but decide to do so in the future?
Ms. Conway, speaking on the NBC program "Sunday Today," said that with a block grant, "you really cut out the fraud, waste and abuse, and you get the help directly" to intended beneficiaries.
Medicaid covers more than 70 million people at a combined cost of more than $500 billion a year to the federal government and the states. More than 20 million people have gained coverage under the Affordable Care Act, more than half of them through Medicaid.
The new Congress has approved a budget that clears the way for speedy action to repeal the health care law, President Barack Obama's signature domestic achievement. And Mr. Trump has said Congress should take action to repeal and replace the law at the same time, putting pressure on lawmakers to agree on an alternative.
As a candidate, Mr. Trump said he wanted to "maximize flexibility for states" so they could "design innovative Medicaid programs that will better serve their low-income citizens." On Friday, in his first executive order, he directed federal officials to use all their authority to "provide greater flexibility to states" on the health law.
As part of their "Better Way" agenda, House Republicans said in June that they would roll back the Affordable Care Act's expansion of Medicaid and give each state a set amount of money for each beneficiary or a lump sum of federal money for all of a state's Medicaid program - "a choice of either a per capita allotment or a block grant."
Governors like the idea of having more control over Medicaid, but fear that block grants may be used as a vehicle for federal budget cuts.
"We are very concerned that a shift to block grants or per capita caps for Medicaid would remove flexibility from states as the result of reduced federal funding," Gov. Charlie Baker of Massachusetts, a Republican, said this month in a letter to congressional leaders. "States would most likely make decisions based mainly on fiscal reasons rather than the health care needs of vulnerable populations."
Gov. Robert Bentley of Alabama, a Republican, said that if a block grant reduced federal funds for the program, "states should be given the ability to reduce Medicaid benefits or enrollment, to impose premiums" or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways.
In Louisiana, Gov. John Bel Edwards, a Democrat, said he was troubled by the prospect of a block grant with deep cuts in federal funds. "Under such a scenario," he said, "flexibility would really mean flexibility to cut critical services for our most vulnerable populations, including poor children, people with disabilities and seniors in need of nursing home and home-based care."
Gov. John W. Hickenlooper of Colorado, a Democrat, said that block grant proposals could shift costs to states and "force us to make impossible choices in our Medicaid program."
"We should not be forced to choose between providing hard-working older Coloradans with blood pressure medication or children with their insulin," Mr. Hickenlooper said.
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September 22, 2014 Monday
Study Finds Small-Business Health Plans Are Cheaper on SHOP
BYLINE: Robb Mandelbaum
SECTION: BUSINESS; smallbusiness
LENGTH: 471 words
HIGHLIGHT: But a researcher who produced the data could not explain why.
On Thursday, in a post answering basic questions about how the Affordable Care Act affects small business, we raised the issue of how insurance premiums purchased on the marketplaces set up for small businesses, known as SHOP exchanges, compare to premiums for insurance purchased off the exchanges. It was something of an unsatisfying discussion.
Insurance that is available both on SHOP and off must carry the same price in both places, but in most states there are many plans available only off-SHOP, and there are competing theories as to whether they cost more or less than exchange plans.
But a few hours after the post was published, we came across some actual data. In testimony before the House Small Business Committee on Thursday afternoon, Jon Gabel, a senior fellow at NORC at the University of Chicago, described research he'd conducted this summer on just this question. In a study of 26 states, Mr. Gabel found that "plans offered on the Marketplace on average have 7 percent lower premiums than plans sold off the Marketplace only. Carriers not participating on the Marketplace have premiums 2 percentage points higher."
Mr. Gabel could not pinpoint a reason for the difference. SHOP plans, he said, may keep costs down by having smaller networks of doctors and other medical service providers. Or it may be that the exchanges are more transparent and competitive, as some advocates for the Affordable Care Act argue. Or perhaps the off-exchange plans offer more benefits than the SHOP plans. Mr. Gabel conducted his research for the Centers for Medicare & Medicaid Services, the government agency that set the rules for the health insurance exchanges and is managing the federally operated exchanges.
The hearing was an effort by Republicans to highlight the shortcomings of the SHOP exchanges, which have been plagued by technical problems and delays, insurer antipathy and small-business indifference. On that last note, Republicans were eager to press the administration to release SHOP enrollment figures. (Hint: they're very low.)
But although the head of the Centers for Medicare & Medicaid Services announced at a separate Congressional hearing on Thursday that 7.3 million people have individual insurance through the exchanges, an official from the agency couldn't answer the very first question put to her by the Small Business Committee.
"In 2014, small businesses had the opportunity to apply for coverage through the SHOP program via paper application utilizing an agent or broker, or directly through issuers," said Mayra Alvarez. "As a result of that, we are not the source of information as far as SHOP enrollment, CMS is not.
"We are working with issuers to get that information," she continued. "And as soon as we get that information we will share it with you - as well as with the American public."
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July 8, 2015 Wednesday
Late Edition - Final
Women Are Paying Less for Birth Control, Study Finds
BYLINE: By SABRINA TAVERNISE
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 1163 words
Out-of-pocket spending on most major birth control methods fell sharply in the months after the Affordable Care Act began requiring insurance plans to cover contraception at no cost to women, a new study has found. Spending on the pill, the most popular form of prescription birth control, dropped by about half in the first six months of 2013, compared with the same period in 2012, before the mandate took effect.
The study, by health economists from the University of Pennsylvania, analyzed health insurance claims from a large private insurer with business in all 50 states and the District of Columbia. It evaluated the effect of the Affordable Care Act, the biggest piece of social legislation in decades, on women's pocketbooks. It estimated that savings from the pill alone were about $1.4 billion in 2013.
Cost has long been a major obstacle to women getting birth control, and declines in what they pay for contraceptives have the potential to increase access and reduce unplanned pregnancies. About half of the 6.6 million pregnancies a year in the United States are unintended, far higher than in most developed countries.
The study, published online in Health Affairs on Tuesday, was not able to definitively establish whether the law drove women's falling expenditures on birth control, but experts said the magnitude and timing of the decline suggested that it was.
Researchers who led the study took a random sample from a private database of millions of patients -- about 790,000 women from 13 to 45 -- and analyzed their contraceptive use from 2008 to 2013. The data was leased by the University of Pennsylvania on the condition that the insurer not be identified.
Experts cautioned that the sample, while large, represented claims from just one insurer and was not designed to be nationally representative. However, they said the trends it showed were convincing. Smaller studies also have found sharp declines in out-of-pocket spending, though experts said Tuesday's study was the largest to date.
''I find this study persuasive and consistent with what other studies are finding,'' said Alina Salganicoff, the director of women's health policy at the Kaiser Family Foundation, a health policy research group, who did not take part in the study. ''I think we're seeing a clear pattern in the research.''
The study did not address whether free or cheaper birth control led to fewer unintended pregnancies. Findings from pilot studies in St. Louis and Colorado suggested that when cost was not an issue, birth control use increased and women tended to choose the most effective methods, such as long-acting intrauterine devices and implants. That helped drive down rates of abortion and unintended pregnancy in both states.
''We have no doubt that the cost makes a difference,'' said Diana Zuckerman, the president of the National Center for Health Research in Washington. ''When you have free contraception, it's going to affect pregnancy and abortion as well because money matters.''
Contraception coverage has improved drastically since the early 1990s, with most insurance companies now covering the full range of birth control methods. But women still had to bear some cost, a requirement that experts say discouraged some lower-income women from getting it and that the Affordable Care Act largely eliminated.
''Co-payments were part of the movement to dissuade people from getting unnecessary care, but they ended up dissuading people from getting necessary care too,'' said Adam Sonfield, a senior policy analyst at the Guttmacher Institute, which tracks reproductive health measures and policies.
The study comes amid growing calls for birth control to be available to women over the counter, a change that some women's groups and professional medical societies support. Such a step would require approval from the Food and Drug Administration, and a Republican bill in the Senate would encourage companies to apply for over-the-counter status for their products.
Opponents have criticized the Republican legislation, saying it could reduce access for women if it meant that birth control was no longer covered in full. (Plans are required to cover most prescription medication, but not over-the-counter medication.) Senator Patty Murray, a Democrat from Washington who helped write the Affordable Care Act, called birth control ''an extremely important part of women's health care and their costs.''
Some Democrats in Congress note that many of the Republican sponsors of the bill on over-the-counter sales have voted to repeal the Affordable Care Act, which mandated the provision of free prescription contraceptives. Republicans say their bill does not take away women's right to get birth control with a prescription, it simply increases women's options.
The Affordable Care Act requires insurance plans to cover the full cost of preventive services, including prescription contraception. The mandate for contraception began in August 2012, and insurers were supposed to comply by the beginning of new plan periods, which for many women was Jan. 1, 2013.
Researchers used data from 2008 as a baseline for spending on prescription contraception, but their analysis compared spending in the first six months of 2012 with that in the first six months of 2013, when the mandate was in effect.
Average spending on the pill dropped by about half to $117 for the first six months of 2013, compared with $244 in the first six months of 2012. Spending per prescription -- which can be up to three months of the pill -- fell to $20.37 from $32.74. Spending on intrauterine devices declined by about 70 percent to about $110. (That includes the cost of insertion but not of removal.)
Average spending on implants, small devices inserted under the skin that prevent pregnancy for several years, declined by about 72 percent to about $91 per device. The steepest decline was for emergency contraception, which fell by more than 90 percent to an average of $1.75 per prescription.
Birth control represented about 44 percent of out-of-pocket spending on medical care in the first six months of 2012 among women in the study. That share had declined to about 22 percent in the first half of 2013. The age groups represented in the study tend to have relatively few health problems.
There were many reasons spending did not fall to zero, said Nora Becker, one of the study's authors. Health plans phased in the requirement, so the change did not happen immediately for everyone, and not all brands were required to be covered. Some older plans were grandfathered -- about a third of all plans in 2013, according to the study -- and others received an exemption for religious reasons. Some plans continued to leave some costs uncovered, a pattern that the Obama administration has warned against.
Spending on two methods in the data remained largely unchanged -- the ring and the patch -- a pattern some experts attributed to that sporadic coverage.
URL: http://www.nytimes.com/2015/07/08/health/after-health-care-act-sharp-drop-in-spending-on-birth-control.html
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GRAPHIC: PHOTO: A pharmacy at a Target store in Brooklyn in June. Out-of-pocket spending on birth control by women dropped sharply after the Affordable Care Act took effect, a study has found. (PHOTOGRAPH BY BRENDAN McDERMID/REUTERS)
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The New York Times
January 20, 2017 Friday 00:00 EST
G.O.P. Governors Seek Flexibility on Medicaid and Health Markets
BYLINE: ABBY GOODNOUGH and ROBERT PEAR
SECTION: HEALTH
LENGTH: 810 words
HIGHLIGHT: Nine governors visiting Capitol Hill criticized the Obama administration as too rigid, but many also urged lawmakers not to repeal the health law without a replacement.
WASHINGTON - Republican governors pleaded with their fellow Republicans in Congress on Thursday to give states more control over both their Medicaid programs and their individual health insurance markets as lawmakers work with President-elect Donald J. Trump to replace the Affordable Care Act.
In town for Mr. Trump's inauguration, nine governors - some who had expanded Medicaid under the law and some who had refused - presented a united message: The Obama administration was too rigid in prescribing standards for Medicaid and private insurance coverage, and states need more power to set their own policies.
Many had already sent letters to Republican lawmakers urging them not to repeal the law before approving a replacement plan, and in comments after Thursday's session they focused on the details of what that replacement plan should be.
Given greater flexibility to set their own policies, several governors said, they would like to trim the number of people in Medicaid and the array of benefits offered in both the public program and private plans sold in the markets.
Yet at the same time, some, including John R. Kasich of Ohio and Asa Hutchinson of Arkansas, are lobbying to keep the generous federal financing provided by the law for expanding Medicaid. Mr. Hutchinson and Mr. Kasich have indicated they would like to reduce their Medicaid expansion populations while still having the federal government pay at least 90 percent of the cost of covering those who remain in the program.
Medicaid is the nation's largest government health insurance program, serving 22 percent of the population - more than 70 million people - at a cost of more than $500 billion a year. Before the Affordable Care Act, Medicaid recipients were largely children, parents, pregnant women and the elderly and disabled.
The law sought to change that by requiring every state to expand Medicaid to cover anyone with income up to 138 percent of the poverty level, or about $16,500 for a single adult. But the Supreme Court ruled that states could opt out of the provision, and many Republican-led states did so.
Still, 16 of the 31 states that expanded Medicaid under the law have Republican governors who now must decide whether to fight to preserve the size and scope of their programs in the Trump era.
The law offered a major financial enticement to lure states into expanding Medicaid: The federal government paid the entire cost for the first three years. Although states are beginning to pay a small portion of expansion costs this year, they are never required to pay more than 10 percent under the terms of the Affordable Care Act.
Some Republican governors have also expressed tentative support for Mr. Trump's proposal to change federal spending on Medicaid from an open-ended entitlement to a fixed annual amount, or block grant, for each state. Critics say block grants could result in states cutting people from the Medicaid rolls or reducing the services they get.
"The difference between a good block grant and a dangerous block grant is in the detail," Mr. Kasich wrote to congressional leaders recently.
Gov. Rick Scott of Florida told reporters outside the meeting room on Capitol Hill that he wanted the Trump administration to give him a set amount for each Medicaid beneficiary, but that the amounts should differ depending on the beneficiary's health needs. "Individuals with different problems, there are different costs involved," he said.
Referring to the Department of Health and Human Services, Mr. Scott added, "It was frustrating to me under Obamacare, where the H.H.S. didn't appear to have any interest in working with me. They said, 'You should do this and do it all 100 percent on my terms.'"
Mr. Hutchinson said he was "very, very pleased" with the meeting with senators, which also included Representative Greg Walden, Republican of Oregon and the chairman of the House Energy and Commerce Committee, which will play a large role in writing legislation to replace the Affordable Care Act. Governors held a separate meeting with Republican members of Mr. Walden's committee.
"Whenever you see senators and Chairman Walden taking notes on what governors are saying, that's a significant day for the principle of federalism," Mr. Hutchinson said.
In addition to Mr. Hutchinson, Mr. Kasich and Mr. Scott, the governors of Idaho, Iowa, Michigan, South Dakota, Texas and Utah attended the meeting.
In letters before the meeting, the governors also warned Congress not to do anything that would disrupt coverage for people who have gained it under the health law.
"We support a single repeal-and-replace package, but are concerned that a strategy to repeal now then later replace the A.C.A. could have serious consequences," Mr. Kasich wrote. He added that such consequences could include destabilizing the insurance markets and reversing recent coverage gains.
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July 21, 2011 Thursday
Late Edition - Final
Gaming Health Care
BYLINE: By ROBB MANDELBAUM
SECTION: Section B; Column 0; Business/Financial Desk; YOU'RE THE BOSS; Pg. 6
LENGTH: 1020 words
That's one notion that seems to be circulating among small-business owners and their advisers lately. Consultants at McKinsey & Company floated the suggestion as part of their controversial report on employer views of health insurance. And in The Times's coverage of that report, Milt Freudenheim interviewed a small-business owner who said he was hoping to ''game the system.'' The owner, Gerry Harkins, who is also chairman of the National Federation of Independent Business's Georgia State Leadership Council, said he might split his Atlanta-based construction company into two smaller companies to evade the overhaul's employer mandate, specifically the penalties on companies that fail to offer affordable health insurance to employees.
Unfortunately for Mr. Harkins (who did not return a call from The Agenda seeking an elaboration of his comments), the authors of the Affordable Care Act are one step ahead of him, according to several tax and benefit lawyers contacted by The Agenda. The authors included a provision that basically adopts parts of the Employee Retirement Income Security Act of 1974 that say any group of companies under common control are to be treated as a single company. Common control is defined as the same five or fewer people owning at least 80 percent of the companies, according to Al Martin, a tax lawyer at the Kansas City law firm Lathrop & Gage. Spouses and children are generally considered one owner, according to Mr. Martin.
No doubt this will make it difficult for people like Mr. Harkins to game the system. ''You're going to wind up changing economic relationships if you avoid the rules,'' he said. ''You've got to change ownership structure.''
''The idea that that would be an easy thing to do would be hard for me to believe,'' added Jon Staudt, a tax lawyer with Belin McCormick in Des Moines. ''People have been trying to avoid the E.R.I.S.A. law so that they could have separate pension plans, for example, pretty unsuccessfully for 36 years.''
The McKinsey consultants, for their part, had other reasons for proposing a split. The thrust of their advice is to find ways to wean lower-wage employees off employer-sponsored coverage while keeping higher-wage employees, who won't be eligible for subsidies, insured.
Until the Affordable Care Act, federal law was a bit schizophrenic when it came to group health insurance plans for 50 or more people. A company that funded its own health insurance plan - a strategy that often makes financial sense for companies with several hundred participants - was subject to an antidiscrimination law that punished those plans for offering looser eligibility requirements or better benefits to top executives.
''The basic rule is you can do anything you want, but if the plan is self-funded, and if the effect of it is that the highly paid get the Cadillac deal and everybody else gets the Ford, that's not going to work,'' said Charles Wolfe, a lawyer at the Chicago law firm Vedder Price, and a co-chairman of an employee benefits committee of the American Bar Association. ''The executives are going to get taxed.''
There was a loophole, however: because group plans insured by a third party (like an insurance company) are regulated by the states, they weren't subject to federal discrimination laws. The solution for big companies, said Mr. Wolfe, was to self fund health insurance for the rank and file and buy a separate insured plan for the executives.
Now the Affordable Care Act is poised to close that loophole by applying the same antidiscrimination rules for self-funded plans to insured plans. (Because the regulations have not been written, the Internal Revenue Service is not yet enforcing this provision of the new law.) One option McKinsey proposes is to split the company into two separate entities, one with company managers and others who would get employer-sponsored insurance and the other for employees who would get no insurance. The company without insurance would have to pay the mandate penalty on those employees, and perhaps even additional compensation, but that could still be cheaper than buying their coverage.
Ah, but beware of free advice, which, as they say, is often worth what you pay for it. Here again, Congress linked the antidiscrimination law for self-funded plans to E.R.I.S.A.'s common-control provision. And the section of the Affordable Care Act that extends the discrimination ban to insured plans explicitly ties the new ban to those same common-control rules. McKinsey's suggestion ''strikes me as a bit odd, in the sense that I don't think it will be possible for a company to keep its corporate or senior management in one company and the rest of its work force in another company and still provide tax-advantaged benefits to the senior management,'' said Philip Mowrey, one of Mr. Wolfe's partners at Vedder Price.
A McKinsey spokeswoman said the firm had no comment.
The penalty assessed under the Affordable Care Act, Mr. Mowrey also noted, was stiff: $100 a day multiplied by every employee discriminated against.
At least in theory, that is. According to Mr. Mowrey, the discrimination regulations for self-funded plans have never really been enforced, because they don't address very well the new types of health care plans that have been developed since the regulations were adopted in 1981. ''It was sort of a moribund law,'' he said. With the expansion created by the Affordable Care Act, he says, it's clear that the I.R.S. is committed to implementing the bans for both kinds of insurance plans.
That means the only way a business owner will be able to beat the health care law by splitting a company into two will be by selling one, or most of one, of the resulting pieces.
4:10 p.m. Clarification A previous version of this post reported that federal law banned self-funded plans from offering looser eligibility requirements or better benefits to top executives. As commenter No. 5 points out (and as we quote Charles Wolfe explaining), the law actually discourages such plans; it doesn't ban them.
This is a more complete version of the story than the one that appeared in print.
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The New York Times
January 9, 2017 Monday 00:00 EST
Muted Response From Health Lobby as Affordable Care Act Faces Repeal
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1688 words
HIGHLIGHT: Fearing they will anger the new administration, some lobbyists have accepted that major provisions are likely to be repealed and have set their sights instead on shaping a replacement.
WASHINGTON - The speed of Republican efforts to repeal the Affordable Care Act has stunned health industry lobbyists, leaving representatives of insurance companies, hospitals, doctors and pharmaceutical makers in disarray and struggling for a response to a legislative quick strike that would upend much of the American health care system.
The Senate is expected to take the first step by Thursday morning, approving parliamentary language in a budget resolution that would fast-track a repeal bill that could not be filibustered in the Senate. House and Senate committees would have until Jan. 27 to report out repeal legislation. Health insurance and health care for millions of Americans are at risk.
But far from reflecting the magnitude of the moment, the most prominent message from lobbyists that lawmakers saw in their first week back at work was a narrowly focused advertisement from the U.S. Chamber of Commerce demanding the repeal of "Obamacare taxes," especially an annual fee imposed on health insurance companies to help pay for the expansion of coverage under the health law.
"More than 20 million people could lose their health insurance, and states could lose billions of dollars in Medicaid money," said Kenneth E. Raske, the president of the Greater New York Hospital Association. But, he added, many health care executives "don't want to get on the wrong side of the new administration or the Republican majority in Congress."
Health care professionals are not totally silent, but industries that were integral to the creation of the Affordable Care Act in 2010 are keeping their voices down as Republicans rush to dismantle it. Some Republican lawmakers are openly fretting about their leaders' repeal strategy, saying they must develop an Affordable Care Act replacement before they repeal it. Five Republican senators proposed on Monday to extend the deadline for drafting repeal legislation by five weeks, until March 3. One of the five, Senator Bob Corker of Tennessee, said the extra time would allow Congress and the Trump administration to "get the policy right" as they try to arrange a smooth transition to a new system of health coverage.
But the naysayers are getting no cover from a major lobbying and advertisement blitz like the ones that blanketed the airwaves in 2009 and 2010.
To block the repeal effort, said Senator Richard J. Durbin of Illinois, the No. 2 Senate Democrat, "we need two or three Republicans to join us."
Doctors are telling Congress to proceed with caution, insisting that no one should lose coverage. The American College of Physicians, representing 148,000 specialists in internal medicine, has sent letters to senators urging them to "vote no" this week on the budget resolution.
Hospitals were expecting to receive tens of billions of dollars in additional revenue for treating people who were newly insured under the health law, and they are alarmed at the prospect that it may now be repealed. But, they say, if Congress goes ahead and rolls back the expansion of coverage, it must also restore tens of billions of dollars that the health law cut from Medicare payments to hospitals.
Top executives from state hospital associations will fly to Washington this week to develop their strategy. Many also plan to visit offices on Capitol Hill, where they will warn of the potential damage if Congress repeals the health law without guaranteeing similar coverage for those who would lose it.
A coalition of consumers and liberal advocacy groups is spending more than $2 million on television advertisements urging Congress to stop its attack on the law. The ads, by the Alliance for Healthcare Security, are aimed at a handful of Republican senators, including Lisa Murkowski of Alaska, Jeff Flake and John McCain of Arizona, Susan Collins of Maine, Dean Heller of Nevada, Lamar Alexander and Mr. Corker of Tennessee, and Shelley Moore Capito of West Virginia.
But by Washington standards, that is a pittance. Pharmaceutical Research and Manufacturers of America, an industry lobbying group, set aside $150 million in 2009 to support the law's passage.
Some lobbyists have tacitly accepted the likelihood that major provisions of the health law will be repealed, setting their sights instead on shaping its replacement. They fear that if they come out strongly in opposition to repealing the law, they will lose their seats at the table as congressional Republicans and the Trump administration negotiate a replacement.
For now, passage of the budget resolution this week looks likely. The real fight is expected to come two to three weeks from now, when two House committees and two Senate committees produce legislation to repeal the Affordable Care Act and must answer to Republicans who say a replacement measure must be ready at the same time.
At least a half-dozen Republican senators have expressed doubts about the Republican leadership strategy of using the budget resolution to fast-track legislation to repeal the law, with a delayed effective date to allow time to find a replacement in the future.
"Repeal and replacement should take place simultaneously," Mr. Corker said last week. Senator Tom Cotton of Arkansas said on MSNBC, "It would not be the right path for us to repeal Obamacare without laying out a path forward."
Members of the hard-right House Freedom Caucus are also pressing leaders to embrace a replacement bill before they eviscerate the existing law.
And that concern is not confined to Congress. Gov. John R. Kasich of Ohio, a Republican, has also warned Congress against repealing the law without a replacement. What, he has asked, will happen to the 700,000 people who have gained coverage under the expansion of Medicaid in Ohio?
Senator Rand Paul, Republican of Kentucky, said that he spoke on Friday with President-elect Donald J. Trump, and that Mr. Trump agreed a replacement measure must be ready.
"I think he consistently has said, and I think many people who look at this say, 'Gosh, you're going to repeal this huge, dramatic thing and not have a replacement on the same day?'" Mr. Paul said on Monday. "I mean, doesn't make a lot of sense to do that."
Many of the lobbyists who might have slowed the process appear flummoxed, in part because they were expecting Hillary Clinton to win the election.
Some companies, anxious about changes in health policy, said they were afraid to speak out because they feared that Mr. Trump would attack them on Twitter, as he has badgered Boeing, Ford, General Motors, Lockheed Martin and Toyota.
Marilyn B. Tavenner, the chief executive of the leading lobby for insurers, America's Health Insurance Plans, is in a particularly awkward position. As an Obama administration official from 2010 to 2015, she led work on the health law, issued rules to carry it out and often defended it on Capitol Hill. In December 2015, Speaker Paul D. Ryan of Wisconsin pointed to her as an example of how federal officials passed through a revolving door to work for companies they once regulated.
"If the insurance industry does not understand how Obamacare works, why not hire the person who ran it?" Mr. Ryan said in a gibe at Ms. Tavenner that drew laughter from his audience at the Library of Congress.
Ms. Tavenner said the requirement for people to have insurance - the individual mandate - was likely to be eliminated. But, she said, to stabilize the market, Congress should maintain "subsidies for low- and moderate-income individuals to purchase insurance and financial help for plans that enroll high-cost individuals, through at least Jan. 1, 2019." She is also asking Congress to kill the tax on insurers, which has already been suspended for 2017.
Kaiser Permanente, the managed care company that serves more than 10 million people, declined to comment specifically on Republican plans to repeal the Affordable Care Act. Instead, it offered a statement of general principles saying that people should have access to health care and that "we must continue to accommodate those who have pre-existing conditions."
George C. Halvorson, a former chief executive of Kaiser Permanente, said insurers were guarded in their comments because the current environment was "extremely politicized." He predicted they have more to say when Congress turns to the task of devising a replacement for the law.
"You need to make your point when it will have optimal impact," Mr. Halvorson said.
Lobbyists for the Blue Cross and Blue Shield Association have been more active and outspoken.
They support changes to the health care law because, they say, premiums and deductibles are too high and commercial insurers have been dropping out of the public insurance marketplaces. One-third of counties in the United States have only one insurer offering coverage in the marketplace, they say, and in many cases, it is a Blue Cross plan.
But Blue Cross lobbyists expressed alarm that Congress or a federal court might eliminate the cost-sharing subsidies that the government pays insurers to reduce out-of-pocket costs for low-income people. Without these payments, Blue Cross wrote in a primer delivered to congressional offices, consumers will see "significant premium increases in 2018, making coverage even more unaffordable for millions of working Americans."
While defenders of the Affordable Care Act try to figure out a strategy, conservative groups are pressing hard for full repeal of the law as soon as possible. Among them are Heritage Action for America, an offshoot of the Heritage Foundation, and Freedom Partners, a conservative group backed by the billionaire brothers Charles G. and David H. Koch.
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Thomas Kaplan and Emmarie Huetteman contributed reporting.
PHOTO: Senator Mitch McConnell, Republican of Kentucky and the majority leader. His party is rushing to repeal the health law. (PHOTOGRAPH BY KEVIN HAGEN FOR THE NEW YORK TIMES) (A14)
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After Obama, Some Health Reforms May Prove Lasting
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May 8, 2013 Wednesday
What Job-Sharing Brings
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 530 words
HIGHLIGHT: For employers, there are benefits and costs to replacing full-time employees with part-time ones, and the Affordable Care Act will provide an interesting case study in how this plays out, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
When employer costs are taken into account, it is unclear whether jobs are something that can be efficiently shared.
The idea behind work-sharing is that employers have a certain amount of work that needs to be done, and that the work can be divided by many employees working a few hours each or a few employees working many hours each. If hours per employee could be limited, by this logic employers would have to hire more employees to get the same amount of work done.
American labor law has traditionally placed some limits on employee hours, such as overtime regulations. While the recent Affordable Care Act does not strictly limit hours per employee, beginning next year it gives employers a strong push toward part-time employment by levying a significant fee per full-time employee and exempting part-time employees from the fee.
A number of employers have said they would change some work schedules to part time from full time to avoid some Affordable Care Act fees. Because part-time workers generally have fewer benefits than full-time employees, this could save employers a considerable sum. From the work-sharing perspective, the part-time employee exemption by itself would be expected to increase employment, because employers would have to hire more people (probably on a part-time basis) to complete work their employees used to accomplish when full time.
But it is possible that work-sharing would reduce employment rather than increase it, because it prevents employers from accomplishing their tasks at minimum cost, adding administrative and coordination expenses. Higher costs for employers may put them out of business, or at least reduce the scale of their business. When companies reduce the scale of their activities, that means fewer employees.
It is also possible that work-sharing would reduce employment by making jobs less attractive to people who desire full-time work. One reason that people sometimes justify commuting long distances to work or enrolling in demanding training programs - trucking and nursing are two such occupations - is that they expect to recoup those cost by taking advantages of opportunities to earn extra by working long hours.
Work-sharing proponents have credited Germany's comparative low unemployment rate to its adoption of a work-sharing program, because the program encourages German employers to reduce employee hours rather than lay workers off. Work-sharing proponents may be right, although Germany carried out a number of labor-market reforms at the same time, such as allowing businesses to use temporary workers more easily.
As the Affordable Care Act suddenly pushes business toward part-time employment, we economists will have an unusual opportunity to learn whether cutting employee hours creates jobs, or destroys them.
The Rise of Part-Time Work
Shorter Hours, but Not for Truckers and Temps
Comparing the World's Glass Ceilings
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
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December 24, 2015 Thursday
The New York Times on the Web
Ad Portrays Marco Rubio as an Action Hero on Health Care
BYLINE: By NICK CORASANITI
SECTION: Section ; Column 0; Politics; THE AD CAMPAIGN; Pg.
LENGTH: 345 words
The main ''super PAC'' supporting Senator Marco Rubio's campaign, Conservative Solutions PAC, is focusing a new ad, titled ''Some Republicans,'' on a cornerstone of his campaign's argument to the Republican base: his legislative efforts to trip up the Affordable Care Act.
On Screen
Graphically crude, the ad seems deliberately rough-hewed. Next to a photograph of the Capitol dome, capital letters declare that, ''On Obamacare, some Republicans gave up.'' Over a yellowing newspaper, a quotation from a New York Times article is highlighted in yellow: ''One Republican presidential hopeful has actually done something.'' The ad quickly becomes a campy mash-up of jump cuts among photographs of Mr. Rubio looking intent and purposeful, and video of him speaking on the Senate floor, over the sort of soundtrack that might have been rejected by the producers of ''MacGyver.'' More quotations, from lesser-known conservative journals, call Mr. Rubio a ''knowledgeable conservative voice'' who ''outsmarts the Democrats.''
The Message
Mr. Rubio's effectiveness at undermining the Affordable Care Act, where others failed or did not even try, went a long way toward answering critics in his own party who have accused him of being a lightweight as a legislator.
Fact Check
While Mr. Rubio's efforts to undermine the Affordable Care Act have caused headaches for the Obama administration and for the law's supporters in Congress, it is still far from clear that they will prove to have ''killed Obamacare,'' as the ad claims.
Where
On broadcast stations in Iowa and New Hampshire.
Takeaway
Within hours of the ad's release online, Mr. Rubio's campaign sent out an email with the subject line ''Marco: The Only Candidate to Strike a Blow to Obamacare,'' pointing to remarks he made on the subject in New Hampshire the same day. Expect to hear a lot more of this from Mr. Rubio and his allies in the weeks to come.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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November 2, 2014 Sunday
Late Edition - Final
The Health Care Law as Equalizer
BYLINE: By KEVIN QUEALY and MARGOT SANGER-KATZ
SECTION: Section BU; Column 0; Money and Business/Financial Desk; Pg. 1
LENGTH: 1275 words
About 10 million more people have insurance coverage this year as a result of the Affordable Care Act. But until now, it has been hard to say much about who was getting that coverage -- where they live, their age, their income and other such details.
Now a large set of data is allowing a much clearer picture. The data shows that the law has done something rather unusual in the American economy of this century: It has pushed back against inequality, essentially redistributing income -- in the form of health insurance or insurance subsidies -- to many of the groups that have fared poorly over the last few decades.
The biggest winners from the law include those ages 18 to 34, blacks, Hispanics and people who live in rural areas. The areas with the largest increases in the health insurance rate include rural Arkansas and Nevada, southwestern Texas, large swaths of New Mexico, Kentucky and West Virginia and much of inland Oregon.
Each of these trends is going in the opposite direction of larger economic patterns. Young people have fared substantially worse in the job market than older people in recent years. Blacks and Hispanics have fared worse than whites and Asians. Rural areas have fallen further behind larger metropolitan areas.
Women are the one modest exception. They have benefited more from the health care law than men, and in the workplace they have received larger raises in recent years. But, of course, women still make considerably less money than men, so an economic benefit for women still pushes against inequality.
The data underlying our analysis came from Enroll America and its partner, the data firm Civis Analytics. The groups used a set of large phone surveys and commercial data to build a model that predicts the odds that any given American has health insurance.
The data set could be analyzed in many ways. The charts on this page offer some important analyses by type.
The Affordable Care Act was passed in 2010, but the law's biggest insurance expansion provisions went into effect in January, when millions more people qualified for state Medicaid programs and new subsidized insurance plans sold in state marketplaces kicked in. The groups estimate that the national uninsured rate for adults under 65 fell to 11.3 percent from 16.4 percent. (More than 98 percent of those over 65 are covered by Medicare.)
''If you look at those who disproportionately gained coverage, it was those who had limited access before,'' said Anne Filipic, the president of Enroll America, a group funded by nonprofits, health care companies and private individuals to help encourage uninsured people to sign up for coverage.
MEDICAID EXPANSION That state boundaries are so prominent in the map attests to the power of state policy in shaping health insurance conditions. The most important factor in predicting whether Americans without insurance in 2013 signed up this year was whether their state expanded its Medicaid program. In states that expanded Medicaid this year, 9.2 percent of adults under 65 are now uninsured, compared with 13.8 percent in those that didn't expand. (Just consider the contrast between Kentucky, which expanded Medicaid, and Tennessee, which did not.)
In 2012, the Supreme Court gave states the right to opt out of the expansion. In all, 26 states and the District of Columbia expanded Medicaid programs this year, and at least one more state -- Pennsylvania -- will expand next year. Predominantly, the states that expanded had Democratic political leadership, while those that declined were governed by Republicans, but there were exceptions in both directions.
RACE Blacks and Hispanics entered 2014 with higher uninsured rates than whites and Asians. That is still the case, but blacks and Hispanics have also shown substantially larger gains in coverage. Matthew Saniie, the director of analytics and data at Enroll, said he attributed the trends to two main factors: existing high uninsured rates for those groups, and disproportionate poverty, meaning more people who qualify for Medicaid. In the case of Hispanics, he said California's huge outreach effort, strongly aimed at its Latino population, gave the group another strong enrollment boost.
AGE Critics of the Affordable Care Act have often warned that it would be unfair to the young because it limits the ability of insurance companies to charge higher rates to older customers, who, on average, tend to be sicker. But young adults show the largest reductions in uninsured rates of any age group. And that's not counting the approximately three million young adults who received coverage on their parents' policies before 2014.
INCOME People with the lowest incomes tended to benefit the most from the law. That makes sense, given how the Affordable Care Act is designed. In states that expanded Medicaid, low-income people can get insurance without having to pay a premium. And for middle-income people who qualify for tax credits to help buy insurance, the subsidies are most generous at the lower end of the income scale. Poorer people were always the least likely to have insurance because their jobs rarely offered it and private premiums were often unaffordable.
POLITICS Despite many Republican voters' strong objections to the Affordable Care Act, parts of the country that lean the most heavily Republican -- according to 2012 presidential election results -- showed significantly more insurance gains than places where voters lean strongly Democratic. That partly reflects underlying rates of insurance. In relatively liberal places, like Massachusetts and Hawaii, previous state policies had made insurance coverage much more widespread, leaving less room for improvement.
But the correlation also reflects trends in wealth and poverty. Many of the poorest and most rural states tend to favor Republican politicians, and the data found that rural parts of America had larger insurance gains than big cities. Of course, the fact that Republican areas showed disproportionate insurance gains doesn't mean that only Republicans signed up. There are many Democrats living in even the most strongly Republican regions.
Over all, the changes tended to be strongest among the groups that were the least likely to be insured. That also means that, in broad demographic terms, the newly insured are not substantially different from the remaining uninsured. There are still many uninsured people, often in places that had high uninsured rates last year. The southern border of Texas, for example, with a large Hispanic population, had some of the largest insurance gains in the country, but still has one of the highest uninsured rates. ''If this was an iceberg or a pile you were trying to work your way through, the composition of the pile hasn't changed very drastically,'' Mr. Saniie said.
The data from Enroll and Civis is the output of a statistical model based on a large survey of adults. That means the numbers are estimates rather than actual observations. For now, Enroll's model showing an overall drop in the uninsured rate lines up with that of other surveys, but no one else has published such detailed findings. Next year, the census will be able to provide a similarly rich picture of the nation's uninsured, using less complex methods.
Civis's background is in political campaign outreach, and many members of both groups support the health law. But both groups say they have no reason for bias. Enroll America's main goal is to find uninsured people so it can sign them up for coverage, so inaccurate numbers would make its job only harder.
The Upshot provides news, analysis and graphics about politics, policy and everyday life.
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GRAPHIC: MAP: Obama's Health Law: Who Was Helped Most: A new data set provides a clearer picture of which groups of Americans gained health insurance under the Affordable Care Act.
CHART: How different groups fared (Source: Enroll America/Civis Analytics) (BU6)
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September 19, 2014 Friday
Late Edition - Final
Health Care Act Still Covers 7.3 Million
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 621 words
WASHINGTON -- The Obama administration said Thursday that 7.3 million people who bought private health insurance under the Affordable Care Act had paid their premiums and were still enrolled.
Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, disclosed the latest count at a hearing of the House Committee on Oversight and Government Reform.
President Obama had announced in April that eight million people had signed up for coverage in the federal and state insurance exchanges, also known as marketplaces.
The chairman of the committee, Representative Darrell Issa, Republican of California, asked why the reported enrollment had dropped by 700,000 people, or about 9 percent.
''Individuals may have gotten employer-sponsored insurance, or found out they were eligible for Medicaid, and some individuals may have decided not to go forward and pay,'' Ms. Tavenner said. Some, she added, may have gone ''into the ranks of the uninsured.''
Federal computer systems still cannot keep a complete, up-to-date count of people enrolled in health plans under the Affordable Care Act, and the government relies heavily on reports from private insurers. With encouragement from the administration, some consumers have signed up or switched plans since April, taking advantage of ''special enrollment periods'' available to people who marry, divorce, have a baby or were stymied by ''technical errors'' at HealthCare.gov.
Administration officials said they were pleased that most consumers were paying their share of premiums. More than 85 percent of people with marketplace coverage are receiving subsidies in the form of tax credits that lower their premiums.
''The vast majority of consumers who gained private insurance coverage through the marketplace are paying $100 or less per month,'' Ms. Tavenner told the committee. ''In fact, nearly half of individuals selecting plans with tax credits in the federally facilitated marketplace -- specifically, 46 percent -- were able to get covered for $50 per month or less.''
The hearing Thursday focused on security weaknesses in HealthCare.gov, the website for the federal insurance exchange.
Gregory C. Wilshusen, director of information security issues at the Government Accountability Office, an investigative arm of Congress, said that federal health officials ''did not assess risks associated with the handling of personally identifiable information.''
The exchanges opened in October, but Mr. Wilshusen said that security testing of the federal website ''remained incomplete'' in June of this year.
Moreover, he said, federal health officials did not always use or require strong passwords and were sometimes slow in applying ''security patches'' to computer systems of the federal exchange.
The administration has often said that Republican concerns about the security of HealthCare.gov were unfounded.
But in her testimony on Thursday Ms. Tavenner said: ''There's very little that concerns me more on a daily basis than the security of this website. I will always worry about the safety and security of the website.''
Hackers broke into part of the federal website in July, but did not steal any personal information on consumers, the administration said early this month. The hackers, it said, placed malicious software onto a test server of HealthCare.gov as part of a broader denial-of-service attack, intended to cripple other websites.
In response to questions on Thursday, Ms. Tavenner said, ''To date we have had no malicious breach, no breach of personal information.'' At another point, she said, ''We haven't had any malicious attacks on the site that resulted in personal information being stolen,'' and she emphasized the word ''malicious.''
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December 3, 2015 Thursday
Late Edition - Final
Health Spending in U.S. Topped $3 Trillion Last Year
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 24
LENGTH: 1044 words
WASHINGTON -- Health spending in the United States last year topped $3 trillion -- an average of $9,500 a person -- as five years of exceptionally slow growth gave way to the Affordable Care Act's expansion of Medicaid and private insurance coverage, and as prescription drug prices resumed their sharp climbs, the government said Wednesday.
Health spending grew faster than the economy in 2014, and the federal share of health spending grew even faster, as major provisions of the Affordable Care Act took effect.
Total spending on health care increased 5.3 percent last year, the biggest jump since 2007, and accounted for 17.5 percent of the nation's economic output, up from 17.3 percent in 2013, the Department of Health and Human Services said in its annual report on spending trends. By contrast, health spending grew 2.9 percent in 2013, the lowest rate of increase since the federal government began tracking it in 1960.
The spending report comes as the Obama administration is already on the defensive over rising premiums and deductibles on insurance policies sold through the health law's exchanges. Last month, UnitedHealth Group, one of the nation's largest health insurance companies, significantly lowered its profit estimates and blamed the federal health care law.
Obama administration officials said Wednesday that the rise in health spending last year did not undermine their conviction that the Affordable Care Act had been a boon for the nation.
''Millions of uninsured Americans gained health care coverage in 2014,'' said Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services. ''And still the rate of growth remains below the level in most years prior to the coverage expansion, while out-of-pocket costs grew at the fifth-lowest level on record.''
But the new report will fuel Affordable Care Act opponents in Congress, who hope to pass legislation this week repealing President Obama's signature domestic achievement. Slowing growth in health spending had been a crucial selling point for supporters of the law.
Anne B. Martin, an economist who was the principal author of the report, said that the growth of health spending last year was in line with projections by her office. The last recession, which began in December 2007 and continued until mid-2009, slowed health spending, as many people lost income and job-based coverage.
Retail spending on prescription drugs increased sharply last year, rising 12.2 percent to $297.7 billion, the administration said in its report, published in the journal Health Affairs.
''This rapid increase, which was the highest rate since 2002, was in part due to the introduction of new drug treatments for hepatitis C, as well as of those used to treat cancer and multiple sclerosis,'' the administration said. The new treatments for hepatitis C, which are highly effective, accounted for $11.3 billion in new spending.
The numbers on retail drug spending do not include drugs administered at hospitals and doctors' offices, where patients receive many high-cost specialty drugs. Spending at those sites is embedded in other categories of spending and is not separately reported.
Many people with hepatitis receive care through Medicaid, the federal-state program for low-income people. ''Medicaid prescription drug expenditures grew 24.3 percent in 2014, up from growth of 4.2 percent in 2013, as a result of increased enrollment and spending for drugs that treat hepatitis C,'' the administration reported.
Senate investigators said Tuesday that the makers of a breakthrough hepatitis drug, Sovaldi, had put profits ahead of patients in setting the initial price at $1,000 a pill, or $84,000 for a standard course of treatment.
Medicare prescription drug spending increased 16.9 percent last year, primarily because of the use of expensive new specialty drugs, including those for hepatitis, the report said.
Richard G. Frank, an assistant secretary of health and human services, predicted that ''faster growth in spending due to rising coverage will be temporary, and will fade in the coming years.''
The report said the number of uninsured people fell by 8.7 million, or nearly 20 percent, to 35.5 million in 2014. As a result, it said, the share of the total population with insurance increased to 88.8 percent, the highest since 1987.
The federal government, which generally paid the full cost of Medicaid for newly eligible beneficiaries and which subsidized private insurance for many other people, accounted for well over half of the increase in national health spending last year.
Over all, federal health spending increased 11.7 percent, to nearly $844 billion in 2014, compared with an increase of 3.5 percent in 2013, the report said.
In addition, it said, ''Medicaid spending by the federal government increased 18.4 percent in 2014,'' to $305 billion, compared with an increase of 6.1 percent in 2013.
Private health insurance spending grew 4.4 percent and reached $991 billion in 2014, accounting for one-third of national health spending.
Total Medicaid spending by federal, state and local government agencies reached $495.8 billion last year, an increase of 11 percent over the prior year, reflecting the fastest rate of growth since 2001. Enrollment in Medicaid increased by 13.2 percent, to 65.9 million people -- the fastest rate of growth since 1991.
But spending per Medicaid beneficiary declined 2 percent, to $7,520, as ''the newly insured tended to be lower-cost individuals,'' the administration said.
''Total Medicare spending reached $618.7 billion in 2014 and accounted for 20 percent of total health expenditures,'' the report said. ''After growing 3 percent in 2013, Medicare spending grew 5.5 percent in 2014. This was the fastest rate of growth since 2009 and was primarily attributable to faster growth in spending for prescription drugs'' and doctors' services, among other factors.
Medicare spending averaged $11,700 per beneficiary last year, representing an increase of 2.4 percent. By contrast, spending per beneficiary was virtually flat in 2012 and 2013.
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January 31, 2017 Tuesday
Late Edition - Final
Protecting Birth Control Access in Oregon
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 28
LENGTH: 405 words
If the Affordable Care Act is repealed, coverage of birth control with no co-payment is one of many benefits that Americans could lose. Now legislators in Oregon have introduced a bill intended to protect access to birth control in the state, along with a broad range of other reproductive health care services, including abortion.
The measure would require insurers in Oregon to cover all contraceptive drugs and devices approved by the Food and Drug Administration with no co-payment, co-insurance or deductible. It would extend the same requirement to a number of reproductive health services, including prenatal care, well-woman visits, screening for sexually transmitted infections, voluntary sterilization and abortion.
The bill also includes a provision that would prohibit insurers from discriminating against patients based on gender identity -- for example, by refusing to cover gynecological exams for transgender women.
Under the Affordable Care Act, 30 million women gained co-pay-free access to preventive services like contraception, according to an estimate by the Department of Health and Human Services. An increase in the use of long-acting birth control methods has helped decrease the rates of unintended pregnancy and abortion nationwide.
By codifying the protections of the Affordable Care Act, the bill would protect Oregonians' access to birth control and other preventive health care in the event of a repeal.
But the Oregon bill would go beyond the Affordable Care Act by establishing a comprehensive list of essential reproductive health services that must be covered without a co-payment. Its sponsors recognized that people need access to the full range of reproductive health care in order to participate fully in society and the economy. Especially for patients with high-deductible health plans, abortion can be prohibitively expensive even if it is covered.
The bill, which is expected to come up for debate in March, may serve as a model for other states. New York is already moving in the right direction, with regulations announced this month to require insurers to provide co-pay-free coverage of contraceptives and abortions deemed medically necessary by a doctor.
Oregon's bill is a powerful defense, at the state level, of necessary reproductive health care.
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December 20, 2013 Friday
The Economics of Being Kinder and Gentler in Health Care
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1246 words
HIGHLIGHT: The high cost of health care in the United States has deterred Americans from taking action to help those who cannot afford it, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
In his speech accepting his party's nomination as presidential candidate on Aug. 18, 1988, George H.W. Bush proclaimed that he wanted a "kinder and gentler nation" - kinder and gentler, I suppose, than he thought it was in 1988.
In those days, my wife and I sent out our own customized holiday cards, commenting in some way on current issues in health policy. Thus, a year after Mr. Bush was elected president, we sent out the following card:
In the late 1980s, about 35 million respondents to large nationwide surveys declared that they lacked health insurance of any kind. The comparable number now is close to 50 million.
Then, as now, the endless "national conversation" went on and on, pondering ways to achieve truly universal health insurance coverage, a feat most other developed nations accomplished long ago.
Then, as now, news organizations and the health services research community reported on the financial and physical hardship that many low-income, uninsured Americans face when they fall ill.
And then, as now, the prices for identical health care goods and services were more than twice as high in the United States as they were - and still are - in the member nations of the Organization for Economic Cooperation and Development. It is why the supply curve of kind acts in the United States shown in the holiday card is far above the comparable curve in other countries.
The point I sought to make with that holiday card was this: Even if the desire to take care of one's poorer or sicker fellow citizens were the same in the United States as elsewhere, a Martian might observe that fewer kind acts are bestowed on the (uninsured) poor in the United States because of the much higher price of American health care.
For all the wonderful things the United States health system has done for the American people, then, as now, it has also helped price some degree of kindness out of our souls, a side effect of their treatments that the leaders of American health care at some point must begin to contemplate.
Does anyone sincerely believe that things have improved in that regard since the late 1980s?
As I showed in a recent post, "The Central Challenge in U.S. Health Policy," the Milliman Medical Index of total health spending for a typical family of four covered by an employment-based preferred-provider health insurance policy, including the total insurance premium and the family's out-of-pocket spending, now stands at $22,000.
Median family income in 2010 was about $60,000 and median household income about $50,000. (A "household" is defined in these statistics as a housing unit with one or more members. A "family" is defined as a household with two or more members.)
These numbers suggest that millions of American households or families have annual incomes of less than $30,000. Without help from other Americans - now typically through the community-rated premiums under employment-based health insurance - they cannot possibly afford the kind of health care the rest of the country enjoys.
(The harsh current critics of community rating rarely complain that the premium contributions by individuals under employment-based health insurance - usually even under the critics' own employment-based insurance - are fully community rated.)
Given the now-staggering cost of buying kind acts in health care for America's low-income families, it is something of a miracle that the Affordable Care Act, with its built-in redistribution of income toward low-income and sicker Americans, passed into law at all.
Nor is it a surprise that it took extraordinarily deft legislative maneuvering to get the law enacted, and that it just squeaked by on a purely partisan vote.
Finally, I am not surprised at the way the federal subsidies to low-income families that the law calls for, and the largely federally financed expansion of Medicaid, had to be scraped together - by an economically unseemly mélange of nuisance taxes here and there and sundry federal spending cuts of projected spending - for the bill to survive both Congress and the scoring process of the Congressional Budget Office.
A simple, earmarked value-added tax, for example, would have been better from an economic perspective, but it would have made the cost of buying kind acts in health care for other Americans more visible.
Now, it may be argued that opposition to the Affordable Care Act is not primarily driven by reluctance to share the blessings of our pricey health care system with low-income Americans who cannot afford it, but rather by misgivings over particular features of the law - for example, community rating and the mandate on individuals to be insured.
I am not persuaded by that thesis, because - as has been pointed out time and again in news coverage - the law largely embodies ideas and features that were quite popular during the 1990s among today's most vocal critics of the law, including Mitt Romney, President Obama's opponent in the 2012 presidential elections.
My interpretation is that opposition to the Affordable Care Act largely reflects the age-old reluctance among many of the nation's haves and the healthy to help purchase for America's lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves. That attitude is all the more striking because of the generous federal indirect subsidies enjoyed by many of the haves, especially high-income Americans. (I am thinking specifically of the generous tax preference accorded employment-based health insurance, the largest tax expenditure in the federal budget.)
Some people on both the extreme left and right seem to believe that the current travails of implementing the Affordable Care Act and the possibility of a so-called "death spiral" in the market for individual health insurance may usher in single-payer health insurance in the United States - say, Medicare for all.
I do not find that a likely prospect. Rather than embracing a single-payer system, the United States is more likely to stumble, in fits and starts, toward something resembling officially sanctioned tiering of the American health care experience by income class, as follows:
For Medicaid beneficiaries and the uninsured, a budget-constrained system of public hospitals and public clinics. It would allow politicians to ration health care (through tight budgets) without ever having to acknowledge that they were doing so. In other words, it would reduce the price of being kind.
For the employed middle class, a mixed system with defined contributions by employers, private health insurance exchanges and reference pricing by insurers. Under a restructured Medicare program also based on a defined contribution model, reference pricing would be likely to apply to Medicare beneficiaries as well. Depending on how it is operated - e.g., if it were solely based on cost, in abstraction of quality - reference pricing also permits tiering of the health care experience by income class, without anyone having to say so openly.
For the upper-income groups, boutique medicine, which is already growing in the United States. Here the sky will be the limit.
And what do readers think?
Health Care Prices Move to Center Stage
Conflicting Pressures on Demand for Doctors
The Single-Payer Alternative
A Conservative Alternative to Obamacare
The Slow Death of the Employer Mandate
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March 8, 2017 Wednesday
Late Edition - Final
G.O.P. Health Bill Meets a Revolt
BYLINE: By JENNIFER STEINHAUER; Thomas Kaplan and Jeremy W. Peters contributed reporting from Washington, and Reed Abelson from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
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WASHINGTON -- After seven years of waiting longingly to annul President Barack Obama's signature health care law, Republican leaders on Tuesday faced a sudden revolt from the right that threatened their proposal to remake the American health care system.
The much-anticipated House plan to repeal the Affordable Care Act also drew skepticism from some of the party's more moderate members, whose constituents have benefited from expanded coverage in recent years.
The criticism came even before lawmakers knew the cost of the replacement plan and how many people might lose their health care if it were enacted.
House Republicans were rushing the legislation through two powerful committees -- Ways and Means, and Energy and Commerce -- with the hope of a full House vote next week, an extraordinarily compressed time frame considering that the legislation affects many parts of the United States economy and could alter the health care of millions of Americans.
But the swift opposition from fellow Republicans signaled that they might have to drastically reconsider their approach, and the White House portrayed the bill as a work in progress. If more than a dozen House Republicans defect, the bill will be in jeopardy, with Democrats almost certainly united as a bloc.
''Doing big things is never easy,'' Speaker Paul D. Ryan conceded at a news conference on Tuesday after absorbing broad-based criticism of the bill. Still, he guaranteed he would drum up the 218 votes needed for passage, saying, ''The nightmare of Obamacare is about to end.''
The Republican bill would eliminate the mandate for most Americans in favor of a new system of tax credits to induce people to buy insurance on the open market. It would also eventually roll back the expansion of Medicaid that has provided coverage to more than 10 million people in 31 states.
Vice President Mike Pence met Tuesday with conservative members of the House to assure them that their feedback was still being considered, and President Trump entertained a group of House Republicans charged with persuading their colleagues to vote for the measure.
''We're going to do something that's great, and I am proud to support the replacement plan released by the House of Representatives,'' Mr. Trump said. ''This will be a plan where you can choose your doctor, and this will be a plan where you can choose your plan. And you know what the plan is. This is the plan. It's a complicated process, but actually it's very simple, it's called good health care.''
Some White House officials insist that Mr. Trump will be directly engaged in persuading lawmakers to back the bill.
But many of the factions that provided financial and political support to back Republicans who vowed to wipe out the Affordable Care Act are nowhere near satisfied with the option rolled out on Monday.
''This is not the Obamacare repeal bill we've been waiting for,'' said Senator Mike Lee, Republican of Utah, who was joined by a constellation of conservative groups, including the Club for Growth, Heritage Action for America and Charles G. and David H. Koch's Americans for Prosperity. ''It is a missed opportunity and a step in the wrong direction. We promised the American people we would drain the swamp and end business as usual in Washington. This bill does not do that.''
The Republican bill would scrap the mandated coverage in the Affordable Care Act in favor of tax incentives to coax people to purchase health care. But the legislation maintains many of the act's mandates and basic benefits, including prohibiting insurers from denying policies for pre-existing conditions or capping benefits in a year or a lifetime.
Some conservatives have labeled the House plan ''Obamacare lite,'' saying it is nearly as intrusive in the insurance market as the law it would replace. In particular, they dislike the delay in getting rid of the law's Medicaid expansion. They also dislike the tax credits in the Republican plan, which can exceed the amount a consumer actually owes in federal income taxes, meaning that the Internal Revenue Service would be issuing checks to cover insurance premiums. The House plan also maintains many of the demands on insurers that the Affordable Care Act has, including a defined suite of ''essential benefits'' that all insurers must offer.
Representative Jim Jordan, Republican of Ohio, said that he would introduce a ''clean repeal'' bill and that Senator Rand Paul, Republican of Kentucky, would offer a companion bill.
Republicans have been counting on Mr. Trump to use his influence to persuade wavering members to support the plan. But despite his characterization of the bill as ''tremendous'' on Tuesday, others in his administration seemed to concede that changes, perhaps major ones, were likely.
Speaking to reporters after meeting with Senate Republicans at the Capitol, Mr. Pence offered the White House's imprimatur, calling the bill the ''framework for reform.'' He added that the administration was ''certainly open to improvements,'' making clear that the wrangling had just begun. Tom Price, the secretary of health and human services, said twice at a briefing with reporters at the White House that the bill was ''a work in progress.''
He also suggested that some provisions Mr. Trump is seeking, like the ability to buy insurance across state lines and the lowering of drug prices, might be addressed through regulation.
Representative Mark Meadows, Republican of North Carolina, said Mr. Pence had portrayed the bill as a work in progress that would no doubt be amended, perhaps significantly. ''The bill that was introduced last night is still open for negotiation and certainly for modification,'' Mr. Meadows said. ''And we took that as very encouraging news.''
Even with substantial changes, passage of the bill is in no way assured. House Republicans accomplished too little in shrinking the size of the government's role in the health sector to pull the most conservative members their way, yet they may not have done enough to allay the concerns of some Republican senators who are skeptical of elements like rolling back the Medicaid expansion and defunding Planned Parenthood.
In an interview with a radio station on Tuesday, Senator Roy Blunt, Republican of Missouri, said, ''What I don't like is it may not be a plan that gets a majority of votes and lets us move on, because I think we can't stay where we are with the plan we've got now.''
The response from insurers was largely muted on Tuesday. They have praised the initial steps taken by the administration to stabilize the individual market, and they said they were encouraged by the desire to provide a smooth transition in the next two years. But several questioned the adequacy of the tax credits.
''It is important that the tax credit for 2020 creates a marketplace that enables people to get the coverage they need at a price they can afford,'' Alissa Fox, a senior vice president at the BlueCross BlueShield Association, said in a statement. ''We look forward to working with Congress to create a stable and affordable private market.''
By proceeding so swiftly, and largely in secret, Republicans have opened themselves to the same criticisms that they leveled at Democrats in 2010. If the bill is passed by the full House as early as next week, Senator Mitch McConnell of Kentucky, the majority leader, has promised to bring it immediately to the Senate floor without a single hearing.
''After years of howling at the moon about Democrats rushing through the Affordable Care Act -- the mantra they said over and over and over again on the floor here and in the House, 'read the bill' -- Republicans are having committee votes two days after the bill is released,'' Senator Chuck Schumer of New York, the Democratic leader, said on the Senate floor. ''No wonder they don't want anyone to know what's in the bill.''
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Senator Rand Paul of Kentucky, center, and other Republicans voiced opposition to the bill. (PHOTOGRAPH BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES)
House Speaker Paul D. Ryan defended the plan at a news conference, saying, ''The nightmare of Obamacare is about to end.'' (A14)
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June 11, 2014 Wednesday
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A Health Insurer Calls, With Questions
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Not long after she signed up for health insurance under the Affordable Care Act, Judy Shoemaker received a phone call that puzzled her.
The caller said she was welcoming new members to the insurance network and then asked Ms. Shoemaker to take a survey about health care issues, so information could be provided to her physician. Ms. Shoemaker declined, saying she didn't understand why her insurer would be seeking medical information to give to her doctor. ''I thought it was strange,'' said Ms. Shoemaker, a consultant to nonprofits in Indiana. ''I can talk to my doctor myself.''
James Tuck, who runs a dog care business in Chicago, got a similar call after signing up for insurance through the Affordable Care Act in March. The caller said he was contacting Mr. Tuck on behalf of his new insurer, Blue Cross Blue Shield of Illinois, to go over his benefits and ask him some questions. Mr. Tuck hadn't yet received his insurance card and was hesitant to answer questions, especially after he consulted a private health advocate, who had helped him evaluate insurance options. She advised him not to answer the queries. ''She said their goal is to find a reason to get you booted off your insurance.''
Insurers say they are doing nothing of the sort. Lauren Perlstein, a spokeswoman for the Health Care Service Corporation, parent of Blue Cross Blue Shield of Illinois and plans in four other states, said in an email that the company contacted new policy holders to help ''new members get the proper coverage and medical assistance they need, by helping guide them through the health care system.''
The company's ''experts'' contact new members to explain benefits and answer any questions, she said, as well as to ''identify members who can benefit from our personalized medical management program so they can best manage their health.''
Medical management options include, for example, programs for expectant mothers, to help make sure they get prenatal care. They are an outgrowth of disease management programs, which aim to improve care and lower costs by helping patients with chronic conditions adhere to treatment regimens.
As of April 30, the company has identified about 38,000 new members who would qualify for medical management programs ''and, by working closely with providers,'' has helped them more easily navigate the health care system to get proper care, she said.
Members aren't terminated because of responses they may give on the calls, she said. Rather, ''this outreach is only to help our members by providing assistance and tools to best manage their health.''
David Nash, dean of the school of population health at Thomas Jefferson University in Philadelphia, said Mr. Tuck had received ''inaccurate'' advice, since the Affordable Care Act bars insurers from considering your health status when enrolling you in coverage.
''It's against the law to deny coverage for any prior conditions,'' Dr. Nash said. Insurers commonly conduct such surveys, known as ''health risk assessments,'' to help make sure members with specific health needs receive proper treatment, as well as to help predict costs so insurers can accurately set premiums. It's understandable, he said, that someone who hasn't had workplace-based insurance, where such assessments are very common, might be taken aback by being asked questions about personal topics, like their exercise habits. But gathering such information helps insurers design sustainable policies, he said.
Yet Sarah O'Leary, who advised Mr. Tuck, said such insurer-initiated calls were reminiscent of those that insurance contractors made before the Affordable Care Act, to help vet applicants for individual policies for pre-existing medical conditions. (One such company contacting consumers on behalf of insurers, she said, is RSA Medical, which previously helped insurers underwrite individual applicants). Her firm, ExHale Healthcare Advocates, advises patients about medical coverage and negotiates medical bills, for fees ranging from $25 to $500 depending on the complexity of the situation.
Ms. O'Leary said she was not aware of any consumers who had been improperly terminated from coverage, but that she considered the calls a ''red flag.'' She advises clients not to answer health questions from their insurers unless they have an active claim.
Here are some questions about keeping your coverage under the Affordable Care Act:
â- What should I do if I get an unsolicited call from my insurer asking health-related questions?
Dr. Nash noted that answering insurer surveys was voluntary, but if you decline you can miss out on programs that may help you.
Cheryl Fish-Parcham, private insurance program director at Families USA, which helps consumers, said health insurance companies were most likely trying to better understand the health profile of new enrollees as a group, to help them design their offerings for next year. Or, they may be trying to get on top of patients with complex needs, such as those who suffer from multiple illnesses. It is up to consumers if they want to answer any questions from their insurer, she said, but consumers ''can rest assured'' that their policies can't be canceled because of their health.
Ms. O'Leary suggests that if you get a call from your insurer that you didn't initiate, you should at the very least hang up and call the number on the back of your insurance card, to make sure the caller is legitimate.
â- Is there any way I can lose my health coverage under the Affordable Care Act?
You can be terminated if you don't pay your monthly premium, so it's important to get your payment in on time. If you get assistance through premium tax credits, or subsidies, you'll have a grace period before your policy is actually canceled, to allow you to catch up. Ms. Shoemaker, the Indiana consultant, said she paid her premium online several days before the due date and then telephoned to confirm her payment was properly credited.
Another way to lose coverage is if you fraudulently filled out your application. It's not entirely clear yet what would be considered fraud, said Karen Pollitz, a health policy expert at the Kaiser Family Foundation. But one classic example might be listing a nonrelative on your application for a family policy in order to gain coverage for them; if the insurer learned the truth later, coverage could be rescinded. Saying that you don't smoke on your application, when in fact you are a smoker, isn't grounds for termination of coverage under the law. But if your status as a smoker is discovered, insurers can retroactively impose higher premiums and cancel you if you don't pay.
â- Can disease management programs be beneficial?
A study by RAND researchers found that disease management programs, which help patients with conditions like diabetes stick to specific medical and drug regimens by, for example, having a nurse call them to remind them to refill prescriptions, can help patients and may save money. (In contrast, generic ''wellness'' programs focusing on, say, weight loss, didn't save money, the study found).
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January 30, 2014 Thursday
An Employer Tells Congress the Health Care Mandate Could Triple His Costs
SECTION: BUSINESS; smallbusiness
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HIGHLIGHT: The issue, as the Republicans and their witnesses at the hearing they convened see it, is that the law defines full-time employment as working 30 hours a week, rather than 40.
On Tuesday, while many were preparing for President Obama's State of the Union address, Republican members of the House Ways and Means Committee dived deep into the Affordable Care Act's employer mandate.
The focus of their scrutiny was the provision in the law that requires companies to offer health insurance to full-time employees in order to avoid paying a penalty. The problem, as seen by the Republicans and their witnesses at the hearing the lawmakers convened, is that the law defines full-time employment as working 30 hours a week, rather than 40.
"The 30-hour rule in the health care law," said Representative Dave Camp, the Michigan Republican who is the committee's chairman, "is forcing employers to make the tough decision of cutting hours and workers, and preventing them from growing their businesses." Mr. Camp said he would prefer to repeal the entire Affordable Care Act, but "that cannot and should not deter us from looking at specific pieces of the law."
His star witness for the inquiry was a relatively small business owner from Maine.
Peter Anastos is co-founder of Maine Course Hospitality Group, which owns and operates a dozen hotels, with three more under construction, in northern New England. It employs 350 people in high season. Maine Course, Mr. Anastos said, has long offered health benefits to employees who work more than 30 hours a week, but he added in his written testimony that it was able to do so only because few employees took the offer. Now, he told the committee, as the law pushes more of his employees to enroll in the company health plan, "This definition of full-time employee is what is going to more than double, and in fact maybe even triple, my costs in the next year alone."
"Businesses such as mine will have far less funds available to expand their businesses," Mr. Anastos continued, although he did not explain why the law, enacted four years ago, has not discouraged his company from building three new hotels.
Mr. Anastos said that he intended to keep his 30-hour policy in place for workers who already have health benefits, but that in order to do that, he would have to bar employees who normally work fewer than 30 hours from picking up extra shifts. At his new hotels, where he plans to employ 150 more people, he said he would keep new hires under 30 hours, at least to start. "I'd like to raise them up," he told a congressman, "but if you're talking about a $10- or $12-an-hour employee, and then it's going to cost $4,000 or $5,000 just to raise them up a couple of hours, it makes it extremely difficult to do."
Mr. Anastos said he feared the requirement would poison his company's relations with its work force. "All these people, we know them well," he said. "I feel like we're driving a wedge between us. It's going to make it so hard when they want more hours to say no to them."
Of course, the Obama administration last year postponed putting the mandate into effect until 2015 to give the Internal Revenue Service time to work out the rules, so none of the consequences that Mr. Anastos described have actually occurred yet. And that left plenty of room for dueling speculation at the hearing.
Lanhee Chen, a research fellow at the conservative Hoover Institution, produced a study that indicated that 2.6 million people would be vulnerable to reduced hours, most of them women and most of them low-earners without college degrees.
Helen Levy of the University of Michigan, the hearing's lone Democratic witness, countered by citing the experiences of Hawaii and Massachusetts, which have already enacted their own health insurance market overhauls.
"While it will always be possible in an economy with 150 million civilian workers to find heart-rending stories of bad things that are happening to people," she said, "the aggregate evidence we have is that the Affordable Care Act will not harm the labor market." Moving the threshold to 40 hours, she said, would leave far more workers vulnerable to reduced hours.
(Mr. Anastos took issue with that claim. "Certainly there are more people closer to 40 hours," he said near the end of the hearing, "but as somebody who's worked many years on the floor by the hour, I would much rather lose one hour of pay - go from 40 to 39 - than go from 40 to 29.")
Tuesday's hearing served to showcase a bill introduced by Todd Young, an Indiana Republican. It would, as Mr. Young put it at the hearing, "restore this traditional definition of full time" - 40 hours a week - "under the Affordable Care Act." Such hearings often pave the way for the committee to consider a bill and forward it to the House floor for debate. This bill has the support of 192 representatives, all of them Republicans, about 80 percent of the Republican conference.
But even if Mr. Young's proposal makes it out of the Ways and Means Committee - the committee has not yet said whether it will take up the bill - it is not clear that House leaders will bring it to the floor. (A spokesman for the majority leader, Eric Cantor, said such announcements normally only come shortly before the chamber is ready to debate a bill.)
Like Mr. Camp, the leaders have indicated that they would prefer to repeal the Affordable Care Act in full. They have voted 40 times to repeal or defund the bill in whole or in part. Only twice, as far as The Agenda can determine, have House Republicans voted to amend a provision and leave the health care law largely intact.
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
Today in Small Business: Founded During the Recession
The Information We Still Need to Manage Our Health Care
Small Businesses Showing Little Interest in State SHOP Exchanges
Here's What My Company Will Pay for Health Insurance
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June 3, 2016 Friday
Late Edition - Final
The Solicitor Who Won Big for Obama Is Leaving
BYLINE: By ERIC LICHTBLAU
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 769 words
WASHINGTON -- The Justice Department announced on Thursday that Donald B. Verrilli Jr., who won historic Supreme Court rulings for the Obama administration on its signature health care law and on same-sex marriage, would be stepping down as the nation's top appellate lawyer.
Mr. Verrilli, 58, has been the solicitor general for five years, arguing the administration's position before the justices during an unusual wave of contentious cases that drew attention far outside the legal world.
President Obama credited Mr. Verrilli in a statement with ''winning landmark cases that moved America forward,'' while Attorney General Loretta E. Lynch said in announcing his departure that ''Don has been at the center of the foremost legal challenges of our time.''
Mr. Verrilli's two most important wins will most likely be remembered as the Supreme Court's 2012 decision upholding the constitutionality of the Affordable Care Act, and its decision last year declaring a constitutional right to same-sex marriage.
The estimated 20 million Americans who gained health care under the Affordable Care Act ''are the ultimate beneficiaries of Don Verrilli's extraordinary work,'' Kathleen Sebelius, who as secretary of health and human services worked with Mr. Verrilli to uphold the law, said in a statement.
The victories were not always graceful, however.
Mr. Verrilli's sometimes halting performance during oral arguments before the justices in the Affordable Care Act case was widely maligned, even earning him ridicule on late-night television from Jon Stewart.
But the court's decision upholding the health care law proved a vindication, and Mr. Obama called him that day to thank him.
One of Mr. Verrilli's arguments for upholding the law was that the penalty for not obtaining health insurance amounted to a tax, not a forced purchase. The argument was critical in earning the deciding vote, by Chief Justice John G. Roberts Jr., in the 5-4 decision.
In that case and others, Mr. Verrilli proved adroit at developing legal strategies targeting particular justices, said Jonathan H. Adler, a law professor at Case Western Reserve University.
''He wasn't a flashy lawyer, and there weren't a lot of sound bites,'' Mr. Adler said. ''But when one looks at his time in office and the cases he argued, history will show that he was a very effective advocate -- and very effective at counting to five and developing legal strategies that got the job done.''
Mr. Verrilli did endure a few big losses that Obama administration officials regretted.
In 2013, in Shelby County v. Holder, the Supreme Court struck down the heart of the Voting Rights Act, passed during the civil rights era, and freed nine states -- most in the South -- to change election laws without federal approval.
The next year, in Burwell v. Hobby Lobby, the court thrilled religious groups when it ruled that requiring family-owned corporations to pay for insurance coverage for contraception violated federal law.
The solicitor general, a position often known as ''the 10th justice'' because appearances before the court are so frequent, has an office inside the Supreme Court.
While Mr. Verrilli's appearances before the court certainly earned him visibility, the bigger measure of his job was in deciding what position the Justice Department should take in thousands of appeals in the federal courts, he told a hometown audience in Wilton, Conn., in 2014.
''That's what I spend most of my time on,'' he said, according to The Wilton Bulletin. ''Arguing cases is a very small part of the job.''
A graduate of Yale and Columbia Law School, Mr. Verrilli was a clerk for Justice William J. Brennan Jr. and argued a dozen cases before the Supreme Court in private practice before joining the Justice Department in 2009.
Mr. Obama nominated him in 2011 as solicitor general to succeed Elena Kagan after she was sworn in as a Supreme Court justice. The Senate confirmed him to the post by a vote of 72-16. Senator Jeff Sessions, an Alabama Republican who was the only senator to speak against him during the floor debate, said he was concerned that Mr. Verrilli and the administration would not be tough enough in terrorism cases.
Mr. Verrilli will step down on June 24. He made no announcement about his plans, but Mr. Obama wished him ''a well-deserved vacation.''
The Justice Department said that Ian Gershengorn, the principal deputy under Mr. Verrilli, would serve as acting solicitor general.
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March 11, 2017 Saturday
The New York Times on the Web
Trump Keeps Low Profile After Praising Health Care Overhaul
BYLINE: By GLENN THRUSH and REED ABELSON; Reed Abelson reported from New York. Thomas Kaplan contributed reporting.
SECTION: Section ; Column 0; Washington; Pg.
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WASHINGTON -- President Trump praised House Republican leaders on Friday for their plan to overhaul the Affordable Care Act, but otherwise kept a conspicuously low profile, with a newfound silent treatment of the news media.
The president's meeting with House leaders came the day after Anthem, one of the nation's largest health insurers, offered strong support for the Republican plan, which has been denounced by other providers and which conservatives have vowed to reject.
Mr. Trump has been noticeably less accessible since unleashing a series of Twitter posts last weekend accusing former President Barack Obama of bugging Trump Tower during the campaign. He briefly spoke with reporters in the Roosevelt Room during the meeting with Republican leaders but did not answer questions.
After he was done, a member of his personal security detail began yelling for the small pool of print and broadcast reporters to clear out of the room quickly, according to a pool report, echoing the sometimes heavy-handed approach of Mr. Trump's team during his campaign rallies.
Mr. Trump thanked the gathering of committee chairmen for their ''diligent work to advance the Obamacare repeal and replacement.''
''That's what people want: They want repeal and replace,'' he said.
The president, according to the pool report, ''did not seem certain that the House Energy and Commerce Committee on Thursday had approved the House health overhaul plan'' but ''verified it with Rep. Greg Walden,'' an Oregon Republican and chairman of the committee.
''We all remember, 'You can keep your doctor, you can keep your plan.' I know, Greg, you've never heard that, right?'' Mr. Trump said. ''It was said many, many times, and it turned out to be not true. This is the time we're going to get it done.''
White House officials have described the Republican bill as a work in progress that is likely to undergo significant change. Earlier this week, it cleared the Ways and Means and the Energy and Commerce committees after marathon sessions to review it. While it still faces potential opposition from the House's conservative Freedom Caucus, Republican leaders plan for the bill to reach the House floor later this month..
On Thursday, Anthem chief executive Joseph R. Swedish praised the bill as addressing ''the challenges immediately facing the individual market.'' He said the proposed legislation ''will ensure more affordable health plan choices for consumers in the short term.''
Mr. Swedish, who has previously warned lawmakers that Anthem will exit some or all of the markets where it offers coverage under the law if significant changes are not made, also said ''the time to act is now,'' because insurers need to set rates beginning next month and decide which, if any, markets they will continue to offer coverage in.
But he was less clear about Anthem's support for all of the provisions in the plan. ''We are thoroughly reviewing and evaluating the legislation further to better understand the changes to both the individual market and the Medicaid program,'' he said.
A major sticking point among members of Congress is when to phase out the expansion of Medicaid under the Affordable Care Act. The bill calls for the expansion to be rolled back in 2020, but some conservatives are demanding it be rolled back in 2018. The House majority leader, Representative Kevin McCarthy of California, said on Friday that it would be ''very difficult'' to speed up the process.
The meeting at the White House came as the president's staff was celebrating the federal jobs report released on Friday, which covered Mr. Trump's first full month in office. In February, the economy added a better-than-expected 235,000 jobs, which prompted a renewed round of jubilant posts on Twitter by some on the president's team.
Dan Scavino Jr., director of the White House social media operation, posted ''235K'' on Twitter with an American flag.
The White House press secretary, Sean Spicer, posted, ''Great news for American workers.''
During Mr. Obama's tenure, his aides were chastened by the volatility of the jobs reports during the 2009 recession and the grinding recovery. They were reluctant to celebrate improved reports for fear of alienating the public, which was still dealing with stagnant wages and an uncertain future.
Mr. Trump and his team have been less circumspect. Mr. Trump often questioned the veracity of the Bureau of Labor Statistics reports during the 2016 campaign, when job growth often exceeded 200,000 a month, arguing that the statistics were rigged to make Democrats look better.
Before he was elected, Mr. Trump dismissed the official data as ''phony'' and ''fiction,'' while arguing -- without evidence -- that the unemployment rate was as high as 42 percent.
There was no hint of that skepticism on Friday morning. At 8:41 a.m., less than an hour after the February numbers were posted, Mr. Trump retweeted a Drudge Report headline that read: ''GREAT AGAIN +235,000.''
The posts by Mr. Trump and Mr. Spicer may have violated a federal rule barring executive branch employees from publicly commenting on principal economic indicators for at least one hour after the official release time.
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June 28, 2012 Thursday
What the Health Care Ruling Means for Medicare
BYLINE: PAULA SPAN
SECTION: HEALTH
LENGTH: 545 words
HIGHLIGHT: Advocates for the elderly largely applauded the Supreme Court decision upholding the Affordable Care Act, saying Medicare beneficiaries would see benefits both now and later.
"This is great news for seniors on Medicare," Paul Nathanson, executive director of the National Senior Citizens Law Center, a nonprofit advocacy group, said in a conference call on Thursday after the Supreme Court issued its ruling upholding the Affordable Care Act.
Because several key provisions involving Medicare kicked in soon after Congress passed the bill in 2010, many beneficiaries won't see big changes in their coverage now. But those improvements could have evaporated had the law been overturned, so the ruling generated sighs of relief among advocacy organizations for older adults.
This means the annual free wellness exam will continue (about 2.2 million people took advantage of it last year, according to AARP), along with the first "Welcome to Medicare" visit, which will remain free, with no out-of-pocket costs.
A number of preventive services, including mammograms, bone scans and depression and diabetes screenings, used to involve deductibles and co-pays; under the Affordable Care Act, they no longer do.
And the gradual closing of the dread "doughnut hole" gap in Part D drug coverage by 2020 will proceed, bolstered by discounts that have already lowered drug costs. "The average Medicare beneficiary will continue to save an average $650 a year," Max Richtman, who leads the National Committee to Preserve Social Security and Medicare, said in Thursday's teleconference. "That's real money, especially for seniors."
On the long-term care front, the court's action preserves several initiatives advancing efforts to support elderly and disabled people in their homes, rather than in nursing homes.
Several are already under way, including the Community First Choice Option, which assists states with the costs of in-home programs for people who would otherwise be institutionalized, and the Balancing Incentive Program, which increases federal matching Medicaid funds in states with less coverage for home and community services.
And starting in 2014, the Affordable Care Act will help husbands and wives hold onto more of their assets if a spouse must spend down to qualify for Medicaid.
Provisions that strengthen efforts to cut Medicare abuse and fraud will survive as well. And if the economics work as the Obama administration planned -- a fairly big if -- Medicare as a whole stays solvent longer.
One murky question concerns Medicaid, and the court's ruling that states that don't agree to expand their coverage can't be penalized by losing their current financing. This could affect millions of people, but "we're not exactly sure of all the ramifications," Mr. Nathanson acknowledged.
Many states might agree to the expansion anyway, said Kevin Prindiville, deputy director of the National Senior Citizens Law Center. "The states get a great deal," he said. "The feds pick up most of the costs."
Amid the general applause from advocates for the elderly, several leaders said they foresaw ongoing Medicaid tussles with Congress and state governments. But for now, they were all smiles.
"A great win," Mr. Prindiville said. "The act is going to improve health for seniors in a variety of ways."
In the Hospital, but Not Really a Patient
L.B.J. Was Wrong
A Benefits Statement You Can Read
Heart Transplants for Older Patients
Tracking Down Government Aid
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October 24, 2013 Thursday
New Year's Baby? You May Pay More
BYLINE: ELISABETH ROSENTHAL
SECTION: HEALTH
LENGTH: 805 words
HIGHLIGHT: While medical conditions and encounters don’t care whether it’s 2013 or 2014, health insurance and subsidies generally play by the calendar year. Having a child early in the year presents some special challenges.
Traditionally, much hoopla surrounds the birth of the first baby of the New Year. But it turns out that can be an expensive bit of good luck.
While medical conditions and encounters don't care whether it's 2013 or 2014, health insurance and subsidies generally play by the calendar year. Deductibles reset on Jan. 1, no matter if you began your six weeks of radiation in December or have been pregnant for the last eight months. And with more and more policies, including those offered under the Affordable Care Act, carrying high annual deductibles of $2,000 or more, that reset can lead to major expenses for consumers who must fulfill the new deductible.
I have spent this year covering medical pricing and have received comments from a number of patients who fell victim to this deductible double jeopardy. Jennifer from Evanston, Ill., wrote:
"My 2nd pregnancy spanned two calendar years, so despite the fact that it was the same pregnancy, I paid my deductible twice, and 20 percent of the hospital charges."
This year, the beginning of the Affordable Care Act health exchanges may amplify the problem for some patients as they switch to new insurance. Rebecca wrote:
"My State Insurance is switching to ObamaCare, and my deductibles start ALL over again with no option to dispute my prenatal and birthing care as an extension of existing care. So, $4,000 deductible and now another $3,000 for the last month and birth."
Unfortunately, that is how insurance works. "Deductibles accumulate on an annual basis, so claims for 2013 accrue until December 31st and then start again for 2014," said Susan Pisano, vice president of communications for America's Health Insurance Plans, a trade group. She noted also that insurance companies generally do their accounting according to when a claim was submitted, not when the service occurred.
This double jeopardy can prove extremely costly in a country where even routine pregnancies ending in simple vaginal delivery can cost $15,000. It may also be burdensome to patients undergoing prolonged or complicated treatment, like breast surgery followed by reconstruction.
Experts point out there are also time constraints built into Health Care Flexible Spending Accounts, which allow consumers to place pretax dollars for unreimbursed medical expenses. But these special accounts also track to the calendar year. Although most plans allow for a grace period of a few months - allowing you, for example, to get reimbursed next March for care rendered this month - ultimately these plans are "use it or lose it." If the money is not spent by the deadline, you lose it. According to Wage Works, the employer keeps the unused portion and generally uses it to defray administrative costs of the plan or, sometimes, to pay for participants who have gone over their limit.
Unfortunately, disputes over hospital bills can take a long time to settle, leaving patients out of luck and money. Dr. Marguerite Duane, a physician who was featured in my recent article on the high costs of pregnancy, thought she was being sensible when she put thousands of dollars into her Flexible Spending Account during her last pregnancy to pay for the unreimbursed expenses related to the birth of her son, Ellis.
But when the hospital mistakenly charged Dr. Duane for an extra night, she spent many months disputing the bill. By the time an accurate bill was generated, she was no longer eligible to use the money.
Which is all to say that, as far as health insurance is concerned, the devil is in the details. And as millions of Americans are signing up for insurance policies under the Affordable Care Act, it pays to scrutinize very carefully how each policy works. Also, as the end of the year approaches, there are ways to minimize your financial exposure, experts said.
Ms. Pisano pointed out, for example, that it might behoove a patient being treated in 2013 to push a hospital to submit the bill as early as possible or schedule elective treatment early in December so that it did not slip into January. Likewise, an obstetrician can bill at the beginning or the end of a pregnancy - a decision that may have huge implications for patient out-of-pocket costs.
In terms of Flexible Spending Accounts, patients don't need to settle billing disputes to tap into these funds, said Jody Dietel, chief compliance officer of the benefits firm WageWorks. They should submit the bill as soon as they get it. If, after adjudication, the final bill is for less than the payout, they will simply have to repay the difference. Said Ms. Dietel: "This is free money, but like coupon shopping you have to be a little organized to use it."
Health Insurance Within Reach
What Does Birth Cost? Hard to Tell
Air Pollution Linked to Lower Birth Weights
Breakthroughs in Prenatal Screening
Breast-Feeding Services Lag Behind the Law
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February 13, 2015 Friday
Late Edition - Final
Save the Children's Insurance
BYLINE: By HILLARY RODHAM CLINTON and BILL FRIST.
Hillary Rodham Clinton, a Democrat, was secretary of state from 2009 to 2013, a senator from New York from 2001 to 2009 and first lady from 1993 to 2001. Bill Frist, a Republican, a surgeon and a businessman, was a senator from Tennessee from 1995 to 2007.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 27
LENGTH: 764 words
NO child in America should be denied the chance to see a doctor when he or she needs one -- but if Congress doesn't act soon, that's exactly what might happen.
For the past 18 years, the Children's Health Insurance Program has provided much-needed coverage to millions of American children. And yet, despite strong bipartisan support, we are concerned that gridlock in Washington and unrelated disputes over the Affordable Care Act could prevent an extension of the program. As parents, grandparents and former legislators, we believe that partisan politics should never stand between our kids and quality health care.
We may be from different political parties, but both of us have dedicated our careers to supporting the health of children and their families. This shared commitment inspired us to work together in the late 1990s to help create CHIP to address the needs of the two million children whose families make too much money to be covered by Medicaid, but cannot afford private insurance.
The resulting program, a compromise between Republicans and Democrats, disburses money to the states but gives them flexibility to tailor how they provide coverage to meet the needs of their own children and families. Some expanded Medicaid; others created separate programs. As a result, the number of uninsured children in America has dropped by half. Children miss less school because of illness or injury, and we've seen a significant decline in childhood mortality.
Today, state governments continue to rely on the program to meet crucial health and budget priorities. It's not surprising that every single governor who responded to a 2014 survey -- 39 in all -- supported saving CHIP.
Of course, the American health care landscape has changed significantly since CHIP started. Under the Affordable Care Act, many families with children are now receiving financial help to enroll in private health coverage through the new health insurance marketplace. But while it is possible that private, family-wide policies offered by employers and marketplaces may one day render CHIP unnecessary, for now substantial gaps still exist -- and too many children can still fall through them.
One specific provision of the Affordable Care Act, often called the ''family glitch,'' has been interpreted to prevent many families from receiving subsidized health coverage in the new marketplace if one parent is offered ''affordable coverage'' through his or her job. In this case, ''affordable'' is defined as less than roughly 9.5 percent of household income for that parent to sign up alone -- even though the actual cost of available family coverage is far higher. For families affected by this glitch, CHIP may be the only affordable option for making sure their children are covered.
We already know what happens when CHIP is no longer an option for families. According to a recent report from the Georgetown University Health Policy Institute, as many as 14,000 children in Arizona lost their health insurance after 2010, when it became the only state to drop CHIP.
We don't want to see the same thing happen across the country. If CHIP is not reauthorized, more families will be hit with higher costs. As many as two million children could lose coverage altogether. Millions more will have fewer health care benefits and much higher out-of-pocket costs, threatening access to needed health services. And because families without adequate insurance often miss out on preventive care and instead receive more expensive treatment in hospital emergency rooms, all of us will be likely to end up paying part of the bill.
While reauthorization is not due until the end of September, Congress needs to act now. With more than four-fifths of state legislatures adjourning by the end of June, lack of action and clarity from Washington by then will make budgeting and planning virtually impossible.
Reauthorizing CHIP for the next four years would cost about $10 billion -- an investment in our children that will pay off for decades to come. This is an opportunity to send a message that Washington is still capable of making common-sense progress for American families.
As 2015 unfolds, we know Congress will continue to debate the future of health care reform. We most likely won't see eye to eye about some of the more contentious questions. But one thing everyone should be able to agree on is that our most vulnerable children shouldn't be caught in the crossfire.
This isn't about politics. It's about our kids and our nation's future. What could be more important than that?
URL: http://www.nytimes.com/2015/02/13/opinion/hillary-clinton-and-bill-frist-on-health-care-for-americas-kids.html
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January 29, 2016 Friday
Hillary Clinton Says Bernie Sanders's Health Plan Will 'Never, Ever Come to Pass'
BYLINE: AMY CHOZICK
SECTION: US; politics
LENGTH: 368 words
HIGHLIGHT: Mrs. Clinton also said that Mr. Sanders’s proposal for a single-payer health care system would thrust the nation into “a terrible, terrible national debate.”
DES MOINES - Hillary Clinton said on Friday that Bernie Sanders's proposal for a single-payer health care system would thrust the nation into "a terrible, terrible national debate" and would "never, ever come to pass."
"People can't wait," Mrs. Clinton said at a rally here on Friday, evoking a sense of urgency and echoing an argument from her most recent campaign ads. "People with health emergencies can't wait for us to have some theoretical debate about some better idea that will never, ever come to pass."
Mrs. Clinton called onto the stage Joan Hannah, who told the story of her daughter's brain cancer and how they were able to receive coverage under the Affordable Care Act, which Mr. Sanders proposes undoing in favor of a "Medicare for all" system.
"People can't wait," Mrs. Clinton said again. "Your daughter calls and says she has a mass in her forehead. You can't wait."
This argument has been distilled into a new ad that went on air in Iowa on Wednesday.
"The American people can't afford to wait for ideas that sound good on paper but will never make it in the real world," Mrs. Clinton says in a voice-over, narration taken from her stump speech.
Mrs. Clinton had largely backed off attacks on Mr. Sanders in her appearances in recent days, instead focusing on her standard stump speech of defeating the Republicans. But health care remains a major point of contention between the two rivals.
Mrs. Clinton supports the Affordable Care Act, but says she would improve on it, including reigning in prescription drug costs. She has clashed with Mr. Sanders who proposes a single-payer system, not because of the idea (which she has advocated in the past) but because she says it is impractical and would destroy the progress made by President Obama's signature domestic achievement.
"We now have a system where you can go into the marketplace," Mrs. Clinton said of the Affordable Care Act. "You don't get asked if you have a pre-existing condition. You just get asked what policy you want and how much you need to help paying for it."
"This is a truly big difference in this campaign," she said. "It's one I want you to think hard about between now and Monday."
Nick Corasaniti contributed reporting
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(The Caucus)
November 19, 2013 Tuesday
Koch Brothers' Group Uses Health Care Law to Attack Democrats
BYLINE: JEREMY W. PETERS
SECTION: US; politics
LENGTH: 409 words
HIGHLIGHT: Americans for Prosperity is targeting three of the most vulnerable Senate Democrats who are up for re-election next year, as well as three House Democrats.
WASHINGTON - Americans for Prosperity, the political group backed by the billionaire brothers Charles and David Koch, is targeting three of the most vulnerable Senate Democrats who are up for re-election next year. The group's efforts are part of a new $3.5 million attack advertising campaign that hammers lawmakers for supporting President Obama's health care law.
The senators - Mark Begich of Alaska, Kay Hagan of North Carolina and Mary L. Landrieu of Louisiana - are all from conservative-leaning states that voted to elect Mitt Romney in 2012. The ads will start running in those states on Wednesday.
Americans for Prosperity is also targeting three Democratic members of the House who are in danger of losing next year: Ron Barber of Arizona, Joe Garcia of Florida and Patrick Murphy, also of Florida.
With the health care law's flaws now front and center, Republicans and their allies have been trying to ratchet up the pressure on Democrats, especially where voters are most likely to respond negatively to the Affordable Care Act.
Tim Phillips, president of Americans for Prosperity, said that reminding voters about problems with the way the law had been carried out so far was part of a much larger strategy.
"We want to make sure Obamacare is the No. 1 issue they're thinking about," he said. "We believe repealing Obamacare is a long-term effort, and a key part of that effort is keeping it in front of the American people night and day."
The ads are specifically aimed at women because the group's research has shown that they are not only more undecided than men about the merits of the Affordable Care Act, but that they also tend to make the decisions about their family's health care.
Women are featured as narrators in the ads.
"Health care isn't about politics," one of those narrators . "It's not about a website that doesn't work. It's not about poll numbers or approval ratings. It's about people. And millions of people have lost their health insurance."
In the commercial that will run in Alaska, a woman talks about the unfulfilled promises made by Mr. Obama and senators like Mr. Begich: "Senator Begich didn't listen. How can I ever trust him again? It just isn't fair. Alaska deserves better."
Lawmakers Point Fingers Over Budget Deadlock
Obama Plans Fund-Raising Trips to Aid Senate and House Candidates
The Weekend Word: School Supplies
10 Questions for President Obama
Obama Tells House Democrats He Will Confront Republicans on Taxes
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July 12, 2016 Tuesday
Late Edition - Final
Obama Offers Ways to Improve His Health Care Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 975 words
WASHINGTON -- After defending the Affordable Care Act in all its intricacies for six years, President Obama proposed ways to improve it on Monday, saying that Congress should provide larger subsidies for private health insurance and create a public plan like Medicare to compete with private insurers in some states.
At the same time, he accused the pharmaceutical industry of trying to protect its profits by opposing any constraints on drug prices.
Mr. Obama offered his views in a valedictory message summarizing what he sees as his legacy on health care, together with his ideas to improve the Affordable Care Act.
He said he was proud of the progress of the last six years, especially the fact that 20 million people had gained coverage because of the law. But he acknowledged that -- despite the title of the law -- health care and health insurance were still unaffordable for some people.
''Too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain uninsured,'' Mr. Obama said in an article published online in The Journal of the American Medical Association.
The article can be read as an effort by Mr. Obama to entrench his approach to health care, which is sure to be debated fiercely by candidates for president and Congress in this election year. Without mentioning names, Mr. Obama aligns himself more closely with the presumptive Democratic nominee, Hillary Clinton, who wants to build on the Affordable Care Act, and he rebuts her Republican counterpart, Donald J. Trump, who promises to replace ''this horrible, stupid Obamacare'' with ''something that's great.''
The number of uninsured has dropped to 29 million, from 49 million in 2010, Mr. Obama said. Many of those who remain uninsured want coverage but say they cannot afford it, he said. Accordingly, he wrote, Congress should increase federal financial assistance to help people buy coverage through public marketplaces like HealthCare.gov.
The online exchanges will be a viable source of coverage ''for decades to come,'' Mr. Obama said, but ''further adjustments and recalibrations will likely be needed.''
Of the 11 million people with marketplace coverage, 85 percent receive tax credits that, on average, cover nearly three-fourths of their premium costs. But for some, said Kristie Canegallo, a deputy chief of staff at the White House, the ''tax credits aren't big enough.''
Mr. Obama said the health law was costing less than originally projected, so Congress could provide more generous subsidies while still keeping federal costs below initial estimates.
White House officials said that Mr. Obama's purpose in writing the article was to start a discussion and suggest a direction for elected officials and future policy makers, but that he would not be offering detailed new legislative proposals to carry out his ideas.
Based on his experience in the last few years, Mr. Obama said, Congress should establish ''a public plan to compete alongside private insurers in areas of the country where competition is limited.''
Most of the country has benefited from competition in the marketplaces, and 88 percent of the people who have enrolled live in counties where at least three insurers offer plans, Mr. Obama said. But, he said, the remaining 12 percent are in areas with only one or two insurers.
Jason Furman, the chairman of Mr. Obama's Council of Economic Advisers, said, ''A public option would be one way to make sure that there was competition everywhere.''
In the debate on health care in 2009 and 2010, Mr. Obama said he supported the idea of a public option, but he did not always insist on it, and the administration sent mixed signals about how important it was.
Reviving the idea on Monday, Mr. Obama said a public plan -- in places lacking competition -- would give consumers more affordable options while also saving money for the government.
''Public programs like Medicare often deliver care more cost-effectively,'' by securing better prices from health care providers, Mr. Obama said. Critics say the savings result, in large part, from price controls imposed by federal laws and regulations.
Mrs. Clinton has proposed her own approach, which would allow people to buy into Medicare.
Medical journals nowadays are full of articles on health policy, but Mr. Obama's is strikingly different in one respect. It includes a blistering attack on Republicans, who he said had tried to sabotage the health care law ''through inadequate funding, opposition to routine technical corrections, excessive oversight and relentless litigation.''
Mr. Obama accused Republicans of ''hyperpartisanship'' without saying what he might have done differently. The law was adopted without any Republican votes, and to this day, polls show public opinion almost evenly split between favorable and unfavorable views of it.
The president described Medicaid as ''a critical piece of unfinished business.'' Because of Republican opposition, he said, 19 states have not expanded Medicaid eligibility. If they did, he said, four million fewer people would be uninsured.
Mr. Obama also assailed ''special interests,'' suggesting that the pharmaceutical industry has been particularly bad.
Drug companies, he wrote, ''oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits.''
In conclusion, Mr. Obama predicted that history would vindicate his work. ''Looking back 20 years from now,'' he said, ''the nation will be better off because of having the courage to pass this law and persevere.''
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URL: http://www.nytimes.com/2016/07/12/us/politics/affordable-care-act-obamacare.html
LOAD-DATE: July 12, 2016
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GRAPHIC: PHOTO: President Obama at the White House last week. In a medical journal, he summarized what he sees as his legacy on health care. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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January 29, 2014 Wednesday
She's a 29er
SECTION: BUSINESS; economy
LENGTH: 617 words
HIGHLIGHT: Provisions of the Affordable Care Act are likely to hurt young women whose employers cut their hours from full time to part time, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Much has been made of the burdens of the Affordable Care Act on healthy young men, but young women are the ones most likely to see the law push them out of full-time work.
A "29er" refers to someone working 29 hours per week, the maximum that an hourly employee can work and still be considered part time by the federal government, as defined under the Affordable Care Act.
Before 2014, when the new federal definition took effect, Census Bureau data suggest that hardly anyone worked exactly 29 hours a week: about one in 1,000. Only six in 1,000 worked 26 to 29 hours a week.
The Affordable Care Act requires that, beginning next January, large employers provide health insurance for their full-time employees (by the federal definition) or pay a penalty per full-time employee on the payroll. The annual penalty is $2,000 and, unlike employee salaries and benefits, is not deductible from business taxes. Small employers do not owe a penalty, unless they cross the 50-employee threshold, in which case the annual penalty is $40,000 for having that 50th employee. Subsequent hires would each carry a $2,000 annual penalty.
Part-time employees do not create a health-insurance requirement or a penalty for their employer, which gives large and small employers an incentive to reduce at least some employees' hours to 29 hours. A number of employers plan to do exactly this.
But the incentives are not limited to penalty avoidance by employers, and began this month. Employees in families with income of less than 400 percent of the poverty line will lose access to generous federal subsidies if they make themselves eligible for employer health coverage by working full time at an employer that offers coverage to such employees.
In other words, employees may have something to gain, or less to lose than they did before this year, by limiting themselves to a 29-hour work schedule. For full-time salaried workers (as opposed to hourly workers) the federal definition is those who work more than three days a week. (For the purposes of discussion, I will refer to the three-day limit as "29 hours," although in practice it may be, say, a 26-hour schedule).
As the new law goes into full effect the next couple of years, I expect that more than 2 percent of workers will be 29ers, an increase by more than a factor of 10. Moreover, as the labor market adjusts to avoid penalties and enhance subsidies, the adjustments will tend to be those that are least costly.
One of the least costly ways to move full-time workers to the 29er group would be to focus on those who already work slightly more than 29 hours. It is usually less costly for a 35-hour-per-week worker to cut hours to 29 than for a 55-hour-per-week worker to do so.
I used the Census Bureau's data to put together a sample of people likely to be 29ers over the next couple of years, based on working 30 to 37 hours per week before this year and not having health insurance available through a spouse (if married). Women outnumber men more than 2 to 1 among likely 29ers. The 29ers are also likely to be less than 30 years old.
Naturally, working fewer hours means less pay. By disproportionately reducing women's work hours, health reform may have the unintended consequence of increasing the gap between men's and women's wages and salaries.
The Tax Equation in the Health Care Law
Shorter Workweeks Are Likely in New Year
Policies That Discourage Full-Time Work
Testing a Premise on the Health Care Law and Part-Time Work
The New Economics of Part-Time Employment, Continued
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May 19, 2014 Monday
Late Edition - Final
More Specious Attacks on Reform
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 16
LENGTH: 646 words
Conservative critics of President Obama's health care reforms are engaged in two long-shot lawsuits to overturn the Affordable Care Act or disable one of its central provisions. Both lawsuits should be recognized for what they really are -- attempts to use the courts to scuttle a law that Congressional Republicans have repeatedly tried, but failed, to repeal through the political process.
One case, now before the United States Court of Appeals for the District of Columbia Circuit, makes the specious argument that the entire law should be overturned because the bill did not ''originate'' in the House. The suit was brought by a conservative legal foundation on behalf of an Iowa artist who does not want to buy health insurance or pay a fine, as the law requires. The lawyers build their entire case on the legislative procedure used when the reform law was passed.
The act started out as a House bill to modify tax credits for certain first-time home buyers and increase the estimated tax payments owed by corporations. That bill passed the House by a vote of 416 to 0 in late 2009. When it got to the Senate, the text and title of the bill were struck and replaced with the text and title of the Affordable Care Act. That version of the bill passed the Senate in late 2009 and then the House in March 2010, when it was signed into law by President Obama.
The plaintiff's lawyers argue that this process violated the ''origination clause'' in Article 1 of the Constitution, which says ''All bills for raising revenue shall originate in the House of Representatives; but the Senate may propose or concur with amendments as on other bills.'' They contend the Senate did not merely ''amend'' the original House bill because the health care reform amendment was not germane to the original bill.
A federal district judge rightly rejected this argument on two grounds last year. First, the reform law is not primarily a revenue-raising measure, though it may incidentally raise some revenue through a fee, called a ''shared responsibility payment,'' on people who refuse to take out health insurance. Second, even if the bill could be construed as a revenue-raiser, it originated in the House. The judge ruled that past Supreme Court decisions allowed the Senate to substitute the entire text and title of a bill and left it to Congress to determine in individual cases whether that was acceptable. In this case, no one in the House challenged the act as a violation of the origination clause.
The plaintiff makes too much of the fact that the Supreme Court, in upholding the constitutionality of the reform law, relied on Congress's authority to raise taxes, not its powers to regulate interstate commerce. That, the plaintiff says, makes it a revenue-raising measure that must originate in the House. But this bill did originate in the House and the House accepted the Senate's amendments without challenging their germaneness.
In a separate line of attack, lawsuits in several states argue that the act allows federal subsidies only for people buying coverage on the 14 state health insurance exchanges, but not for people buying on the exchanges run by the federal government in the 36 states that refused to set up their own. That contention was slapped down in one case in January by a federal district judge, who concluded that the law was designed to provide quality, affordable health care for ''virtually all'' Americans, not just those buying insurance on state-run exchanges. In March, a federal appellate court panel heard arguments on this case.
The opponents of health care reform are making desperate arguments that defy common sense and the purpose of a law that was approved by the political process and is providing benefits to tens of millions of Americans. Should these cases somehow reach the Supreme Court, the justices should reject their arguments outright.
URL: http://www.nytimes.com/2014/05/19/opinion/more-specious-attacks-on-reform.html
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The New York Times
November 30, 2016 Wednesday
Late Edition - Final
Health Dept. Nominee
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 22
LENGTH: 230 words
To the Editor:
Re ''Fierce Critic of Health Care Law Said to Be Pick for Health Dept.'' (front page, Nov. 29):
Representative Tom Price, an orthopedic surgeon from Georgia, is expected to be nominated as secretary of health and human services. You note that in the 2009 debate over the Affordable Care Act, Dr. Price called the federal government ''stifling and oppressive.''
It is true that the act does establish requirements for health insurers. Among other things, insurers cannot deny coverage to people with pre-existing conditions or charge them more than others, and they may not establish annual or lifetime limits.
While Dr. Price may consider those ''stifling and oppressive,'' most Americans would choose the Affordable Care Act's protections over the conditions that existed before the law's passage.
Dr. Price's ''most frequent objection to the law is that it interferes with the ability of patients and doctors to make medical decisions.'' Yet there is absolutely no evidence of that.
We may not agree on policy preferences, but if we could at least begin the policy discussion from a foundation of fact, that would be a small amount of progress.
STEPHEN M. DAVIDSON
Boston
The writer is a professor at the Questrom School of Business, Boston University, and the author of ''A New Era in U.S. Health Care: Critical Next Steps Under the Affordable Care Act.''
URL: http://www.nytimes.com/2016/11/29/opinion/tom-price-health-dept-nominee.html
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January 10, 2017 Tuesday 00:00 EST
Trump Tells Congress to Repeal and Replace Health Care Law 'Very Quickly'
BYLINE: MAGGIE HABERMAN and ROBERT PEAR
SECTION: US
LENGTH: 1342 words
HIGHLIGHT: President-elect Donald J. Trump said he wanted to replace the Affordable Care Act as soon as it was repealed, but some Republicans want more time to consider an alternative.
President-elect Donald J. Trump demanded on Tuesday that Congress immediately repeal the Affordable Care Act and pass another health law quickly. His remarks put Republicans in the nearly impossible position of having only weeks to replace a health law that took nearly two years to pass.
"We have to get to business," Mr. Trump told The New York Times in a telephone interview. "Obamacare has been a catastrophic event."
Mr. Trump appeared to be unclear both about the timing of already scheduled votes in Congress and about the difficulty of his demand - a repeal vote "probably some time next week" and a replacement "very quickly or simultaneously, very shortly thereafter."
But he was clear on one point: Plans by congressional Republicans to repeal the health law now, then take years to create and implement a replacement law are unacceptable to the incoming president.
Republican leaders have made the repeal of President Obama's signature domestic achievement a top priority. They hope that the Senate will vote on Thursday and the House will vote on Friday to approve parliamentary language created to protect repeal legislation from a filibuster in the Senate.
The House speaker, Paul D. Ryan of Wisconsin, who consults often with Mr. Trump, set out a similar timetable on Tuesday, saying that a bill to repeal the health care law would include some legislation to replace aspects of it, though Republicans have yet to agree on the details of their alternative.
"It is our goal to bring it all together concurrently," Mr. Ryan said.
But those ambitions will be difficult to achieve and will almost certainly require Democratic cooperation. Until now, Republicans could vote to repeal Mr. Obama's health law with no fear that they would have to live with the political consequences of scuttling a law that provides health care for 20 million Americans and protects millions more from discrimination for pre-existing medical conditions, ends lifetime caps on insurance coverage and allows children to remain on their parents' insurance policies until age 26.
With complete control of Washington, what comes next in health policy will belong to the Republican Party. For several days, congressional Republicans of diverse political views - moderates and conservatives alike - have been saying they are nervous about repealing the law without any clear path forward. Five Senate Republicans have pressed to delay the deadline for committees to produce repeal legislation until March, and several House Republicans are also demanding that the pace slow down.
"In an ideal situation, we would repeal and replace Obamacare simultaneously, but we need to make sure that we have at least a detailed framework that tells the American people what direction we're headed," said one of those five Republicans, Senator Susan Collins of Maine.
As it stands, the budget resolution that will fast-track that vote gives Senate and House committees until Jan. 27 to write legislation that would repeal major provisions of the health care law. But the schedule for action on that legislation, its effective date and the timetable for phasing in a new system of health insurance coverage are all unresolved questions.
Even the Jan. 27 deadline is not enforceable or particularly meaningful, Senate aides said, indicating that Congress could follow any timetable its leaders might prescribe.
That uncertainty apparently persuaded Mr. Trump to leap into the fray. Not only did he try to steel Republican spines, but he threatened Democrats who might stand in his way, saying he would campaign against them, especially in states that he won in November.
"It may not get approved the first time, and it may not get approved the second time, but the Democrats who will try not to approve it" will be at risk, he said, warning that "they have 10 people coming up" for re-election in 2018. That alluded to Democratic senators in states he won.
"I won some of those states by numbers that nobody has seen. I will be out there campaigning," he said.
He described the health law as a catastrophe. "I feel that repeal and replace have to be together, for, very simply, I think that the Democrats should want to fix Obamacare," he said. "They cannot live with it, and they have to go together."
After meeting on Tuesday with House Republicans, Mr. Ryan took a similar tone, calling the campaign to repeal the health law "a rescue mission to save families who are getting caught up in the death spiral that has become Obamacare."
Aides to Mr. Ryan said the effort to dismantle the Affordable Care Act would include not only the main bill that would be protected from a filibuster in the Senate, but also legislation that would not enjoy such protections. That legislation would take Democratic cooperation to be passed because Senate Republicans are eight votes short of a filibuster-proof majority.
Congressional Democrats say that the Affordable Care Act, far from being in a "death spiral," is one of the best health laws since the creation of Medicare and Medicaid in 1965. And the Obama administration reported on Tuesday that more than 11.5 million people nationwide had signed up for health insurance or been automatically re-enrolled under the Affordable Care Act as of Dec. 24, 2016, an increase of nearly 300,000 from this time last year.
Of that total, officials said, more than 8.7 million people came in through HealthCare.gov, the online federal marketplace, and 2.8 million were enrolled in states using their own marketplace platforms.
"Today's data show that this market is not merely stable, it is actually on track for growth," Aviva Aron-Dine, a senior counselor to Sylvia Mathews Burwell, the secretary of health and human services, said in a conference call with reporters. "Today we can officially proclaim these death spiral claims dead."
The fourth annual open enrollment period started on Nov. 1 and ends on Jan. 31, 11 days after Mr. Trump's inauguration.
The enrollment numbers have some Republicans nervous. "The fear is that the strategy is repeal and delay, and then hope for the best, when we should be planning for the worst," said Representative Charlie Dent of Pennsylvania, a chairman of the moderate Republican caucus known as the Tuesday Group.
Republican leaders tried on Tuesday to ease such concerns. But they may be making promises that will be difficult to keep.
"Let me be clear," Representative Cathy McMorris Rodgers of Washington, the chairwoman of the House Republican Conference, told reporters. "No one who has coverage because of Obamacare today will lose that coverage. We're providing relief. We aren't going to pull the rug out from anyone."
The Obama administration also provided new information to Congress on Tuesday about one of the most unpopular provisions of the health care law, which imposes tax penalties on people who go without insurance and do not qualify for an exemption from the requirement to have coverage.
The commissioner of the Internal Revenue Service, John A. Koskinen, reported that 6.5 million taxpayers were subject to penalties last year. The penalties totaled $3 billion, he said. The average payment was about $470.
Under another section of the health law, low- and moderate-income people can obtain subsidies, in the form of tax credits, to help pay for insurance bought through a public marketplace. In 2016, Mr. Koskinen said, 5.3 million taxpayers claimed $19.2 billion in premium tax credits, for an average of about $3,620.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
Margot Sanger-Katz and Emmarie Huetteman contributed reporting.
PHOTO: Speaker Paul D. Ryan on Monday in Washington. He said Tuesday that details of a replacement law had not been agreed on. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A11)
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December 9, 2013 Monday
Parties in California Squabble Over Another Website
BYLINE: Ian Lovett
SECTION: US
LENGTH: 669 words
HIGHLIGHT: Democrats in California are accusing the state’s Republicans of trying to sabotage the new state-run health insurance exchange by putting up their own website that Democrats call misleading. Republicans say they’re just trying to help consumers confused by the new law.
LOS ANGELES - California has enjoyed one of the smoothest rollouts of a health care exchange in the country. But the state's Democrats are accusing Republicans of trying to sabotage the state-run exchange by putting up their own health care website.
Last week, Jimmy Gomez, a Democratic state assemblyman, called for an investigation intothe site created by Republicans in the state Assembly. He also sent a letter to the Assembly rules committee urging it to take down the site, which he said was an effort to "deceptively mislead" consumers away from the state exchange, Covered California.
The Republican website initially had only a few links to the state's health care site, though more were added after Democrats complained. It also prominently features newspaper articles critical of the Affordable Care Act, as well as a feature that allows people to calculate the penalty they will have to pay if they do not buy health insurance. There is no tool, however, for calculating tax credits that might lower premiums for consumers.
A small disclaimer at the bottom of the website is the only link to any affiliation with Assembly Republicans.
"It is clear that the only goal of this website is to present the California Health Benefit Exchange in a deceptively misleading and negative perspective by highlighting penalties, featuring negative stories on the Affordable Care Act and creating a narrative of unaffordable health insurance through the exchange," Mr. Gomez wrote in his letter to the rules committee.
Republicans in the Assembly have maintained that the website, which has been active since August but only recently drew the public ire of Democrats, is simply an attempt to answer constituents' questions about the health care law and to help them understand their options.
"Believe it or not, we are trying to be proactive and helpful," said Connie Conway, the Republican Assembly leader. "I understand the other side really wants to push only the positive parts of the law. But we want to let our constituents know, hey, there are traps out there. There are good parts, which we point but. But proceed with caution."
A 2012 law bars any organization from claiming to provide services from the state exchange if they have not been approved to do so. Last month, the state shut down 10 websites that the California attorney general said were fraudulently imitating the state exchange.
Mr. Gomez suggested that the Republican site violates that law, because its name is similar to the state-run exchange's and because it includes tabs for people with insurance, people without insurance and employers, much like the state website.
Those who click on a tab labeled, "Seniors," find a warning: "Seniors on Medicare may not see changes immediately to their benefits or coverage. Down the line, however, the erosion and accessibility of care may become a problem."
Mr. Gomez said on Twitter on Thursday: "Can u tell which site is legit? http://coveredca.com vs http://coveringhealthcareca.com Tell Repubs 2 Fess Up & take down misleading site."
Ms. Conway said the party's website, as well as letters Republicans have sent to constituents directing them to the site, have been approved already by the rules committee. She said the Republican site had a similar layout to "microsites" on other issues run by the Republican caucus, such as one on how to pay for college.
She called criticism of the website an attempt to distract from the many problems with the rollout of the federal health insurance website.
"They are looking for any excuse to blame it on somebody else," Ms. Conway said of the Democrats. "But the buck stops at their door. The law is going to succeed or fail on its own merit. I don't have control of whether it succeeds, and I'm not trying to control that."
White House to Tweak Tax-Penalty Deadline
Polls in Overtime on Affordable Care Act
Enrollment Numbers Rise After Website Improves
Maine Hires Firm to Study Medicaid System, to Democrats' Ire
Programmers Find New Way to Navigate Health Plans
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November 13, 2014 Thursday
The New York Times on the Web
Law in the Raw
BYLINE: By LINDA GREENHOUSE
SECTION: Section ; Column 0; OpEd; CONTRIBUTING OP-ED WRITER; Pg.
LENGTH: 1718 words
Nearly a week has gone by since the Supreme Court's unexpected decision to enlist in the latest effort to destroy the Affordable Care Act, and the shock remains unabated. ''This is Bush v. Gore all over again,'' one friend said as we struggled to absorb the news last Friday afternoon. ''No,'' I replied. ''It's worse.''
What I meant was this: In the inconclusive aftermath of the 2000 presidential election, a growing sense of urgency, even crisis, gave rise to a plausible argument that someone had better do something soon to find out who would be the next president. True, a federal statute on the books defined the ''someone'' as Congress, but the Bush forces got to the Supreme Court first with a case that fell within the court's jurisdiction. The 5-to-4 decision to stop the Florida recount had the effect of calling the election for the governor of Texas, George W. Bush. I disagreed with the decision and considered the contorted way the majority deployed the Constitution's equal-protection guarantee to be ludicrous. But in the years since, I've often felt like the last progressive willing to defend the court for getting involved when it did.
That's not the case here. There was no urgency. There was no crisis of governance, not even a potential one. There is, rather, a politically manufactured argument over how to interpret several sections of the Affordable Care Act that admittedly fit awkwardly together in defining how the tax credits are supposed to work for people who buy their health insurance on the exchanges set up under the law.
Further, the case the court agreed to decide, King v. Burwell, doesn't fit the normal criterion for Supreme Court review. There is no conflict among the federal appellate circuits. (Remember that just a month ago, the absence of a circuit conflict led the justices to decline to hear seven same-sex marriage cases?) In the King case, a three-judge panel of the United States Court of Appeals for the Fourth Circuit, in Richmond, Va., unanimously upheld the government's position that the tax subsidy is available to those who buy insurance on the federally run exchanges that are now in operation in 36 states.
A panel of the United States Court of Appeals for the District of Columbia Circuit ruled 2-to-1 the other way, accepting the plaintiffs' argument that the language of the statute limits the tax subsidies to those who buy insurance through the state exchanges, which only 14 states have chosen to set up. The full appeals court quickly vacated the panel's judgment and agreed to rehear the case. The new argument was set for next month, and the briefs were already filed. The absence of a circuit conflict and an imminent rehearing by the country's most important court of appeals would, in the past, have led the Supreme Court to refrain from getting involved.
So no, this isn't Bush v. Gore. This is a naked power grab by conservative justices who two years ago just missed killing the Affordable Care Act in its cradle, before it fully took effect. When the court agreed to hear the first case, there actually was a conflict in the circuits on the constitutionality of the individual insurance mandate. So the Supreme Court's grant of review was not only unexceptional but necessary: a neutral act. The popular belief then that the court's intervention indicated hostility to the law was, at the least, premature.
Not so this time. There is simply no way to describe what the court did last Friday as a neutral act. Now that the justices have blown their own cover, I notice the hint of a slightly defensive tone creeping into the commentary of some of those who have been cheering the prospect of rendering the Affordable Care Act unworkable: that as a statutory case, without major constitutional implications, any problems for ordinary Americans that result from a ruling against the government can be fixed by Congress (where House Republicans have voted 50 times to repeal the entire law) or by the states themselves (36 of which failed to set up their own exchanges, thus requiring the federal government to step in as provided by the law).
Sure.
It bears repeating that what's at stake is whether the Affordable Care Act can continue on its successful trajectory or whether it will collapse into the ''death spiral'' it was structured to avoid. The reason goes back to the individual mandate, the constitutionality of which the Supreme Court upheld by a 5-to-4 vote two years ago. The policy reason for requiring everyone to carry health insurance is to guarantee a big pool of basically healthy people and to prevent what might otherwise be the smart strategic behavior of buying insurance only when illness strikes (behavior the law's ''guarantee issue'' provision would otherwise invite, since no one can be turned down on the basis of a pre-existing condition.)
The law is also designed to make insurance affordable, with no one being required to spend more than 8 percent of his or her income of health insurance.
Federal income tax subsidies available on the exchanges are supposed to bring premium costs below that threshold; without the credits, many people would be exempt from the individual mandate and the law would fail.
Congress assumed that most states would set up exchanges; most states, led by red-state governors, did not. Section 1321 of the law provides that when a state defaults, the secretary of health and human services shall ''establish and operate such Exchange within the State.'' Clear enough: ''such Exchange'' implies, without explicitly saying so, that the federal exchange stands in for the missing state's exchange and assumes its functions. But another section, 1401, explicitly makes the tax subsidies available to taxpayers and their dependents who buy insurance ''through an Exchange established by the State.'' Those challenging the law say this means ''only the state'' and that the I.R.S. is not authorized to give subsidies to the more than five million people enrolled through federally run exchanges.
These two provisions, part of a 900-page statute that was cobbled together without going through the usual House-Senate conference committee in which it might have been cleaned up, are the source of the confusion. The answer to the problem, as the Fourth Circuit panel found unanimously in the King case, is obvious. It's a basic principle of administrative law that when a federal statute is ambiguous, courts defer to the agency's interpretation -- here, the I.R.S. regulation that makes the tax credits available without regard to whether the exchange is state or federal.
The 1984 decision that established this deference principle, Chevron U.S.A. v. Natural Resources Defense Council, Inc., is so central to the modern understanding of how the government works that it is among the most often invoked Supreme Court decisions of all time, cited in some 13,000 judicial decisions so far, a number that grows at the rate of about 1,000 a year. The tax provisions of the Affordable Care Act fall so naturally onto the ''Chevron deference'' landscape that it would take an agenda-driven act of judicial will to keep them out and to conclude that Congress enacted a law that contained the seeds of its own destruction.
Chief Justice John G. Roberts Jr. knows something about taxes. He saved the Affordable Care Act from his usual allies two years ago by his opinion deeming the individual mandate's penalty provision to fall within Congress's tax power. This case puts him back under what I can only assume is an unwelcome spotlight.
It takes the votes of four of the nine justices to accept a case. Certainly Justices Anthony M. Kennedy, Antonin Scalia, Clarence Thomas, and Samuel A. Alito Jr. -- the four who two years ago would have invalidated not only the individual mandate but the entire law -- voted to hear King v. Burwell. (Michael A. Carvin, the plaintiffs' lawyer, predicted as much last month, declaring in an uninhibited interview that the pending rehearing before an appeals court that has recently attained a majority of Democratic-appointed judges would be no deterrent to the justices who wanted to take the case. ''I don't know that four justices, who are needed here, are going to give much of a damn about what a bunch of Obama appointees on the D.C. Circuit think,'' he told a reporter from Talking Points Memo.)
An intriguing question is whether there was a fifth vote as well, from the chief justice. I have no idea, although I can't imagine why he would think that taking this case was either in the court's interest or in his own; just two months ago, at a public appearance at the University of Nebraska, he expressed concern that the ''partisan rancor'' of Washington could spill over onto the court.
Here's another possible scenario, just a theory: that the four, still steaming over what the right wing regards as the chief justice's betrayal two years ago, voted to hear King v. Burwell not only for its destructive potential, but precisely to put the heat on John Roberts. I hadn't really focused on this idea until I read a piece that John Yoo posted on National Review Online the day after the court granted the case. Professor Yoo, formerly of the Justice Department's Office of Legal Counsel and now at the University of California at Berkeley, wrote that the new case gave the chief justice ''the chance to atone for his error in upholding Obamacare'' and that ''it will be the mission of his chief justiceship to repair the damage.'' John Yoo -- yes, the Bush administration lawyer whose ''torture memos'' attempted to justify that administration's ''enhanced interrogation'' policies -- is a smart man, a former law clerk to Justice Thomas who remains well connected at the court. His choice of the words "atone'' and ''mission,'' with their religious resonance addressed to the devoutly Catholic chief justice, is no accident.
So this case is rich in almost every possible dimension. Its arrival on the Supreme Court's docket is also profoundly depressing. In decades of court-watching, I have struggled -- sometimes it has seemed against all odds -- to maintain the belief that the Supreme Court really is a court and not just a collection of politicians in robes. This past week, I've found myself struggling against the impulse to say two words: I surrender.
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March 28, 2015 Saturday
Late Edition - Final
Long Night in Senate, but Real Budget Work Awaits
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 1054 words
WASHINGTON -- Emerging from an all-night session that was more exhausting than dramatic, Senate Republicans on Friday squeaked through a budget blueprint that would repeal the Affordable Care Act, fundamentally remake federal health care for the poor and elderly, and push the federal deficit toward zero over the next decade.
The 52-to-46 vote came at 3:28 a.m. after the Senate considered hundreds of amendments and voted on dozens -- many of them politically freighted, some of them contradictory, but none of them binding. No Democrats voted for the budget. Among Republicans, only Senator Rand Paul of Kentucky, who is likely to seek the White House, and Senator Ted Cruz of Texas, who has announced his intention to do so, voted no.
Senator Michael B. Enzi of Wyoming, the chairman of the Budget Committee, hailed a plan that he said would ''protect the nation's most vulnerable citizens, strengthen national defense and bring robust economic growth.''
Democrats said it would be a disaster -- if it ever happened.
The House passed its budget plan on Wednesday. Now, Senate and House negotiators hope to take similar tax-and-spending plans and negotiate the first common congressional budget in a decade.
Then would come the difficult work, turning a hard-fought, aspirational document into the actual legislation that the budget promises: an end to the Affordable Care Act; a Medicare system transformed, with vouchers for older adults to buy private insurance; drastic cuts to Medicaid and food stamps, which would be turned over to the states; and a simplified tax code with a far lower top income tax rate.
''Fortunately for the country, the Republican budget will not become law,'' said Senator Harry Reid of Nevada, the minority leader.
Representative Paul D. Ryan of Wisconsin, who as the House Ways and Means chairman will have his hand in much of the legislative effort, was taking a step-by-step approach to the task. He said a series of legislative deadlines would guide Congress more than the budget's prescriptions.
The expiration of the highway trust fund on May 31 will be the first order of business. President Obama and lawmakers in both parties have proposed a novel way of funding a major infrastructure effort: mandate the repatriation of hundreds of billions in corporate profits stashed overseas, then tax it at a special low rate, with the proceeds dedicated to roads, bridges, transit and airports.
But Mr. Ryan and the president want that initiative to be part of a much broader overhaul of the business tax code that would lower the corporate tax rate and close loopholes. The Senate on Thursday night approved an advisory amendment from the chairman of the Finance Committee, Orrin G. Hatch of Utah, and its ranking Democrat, Ron Wyden of Oregon, ordering just such an overhaul by voice vote.
Mr. Ryan said conversations had already begun about a short-term highway trust fund extension as both chambers try to build momentum for a rewrite of the business tax code.
The next deadline is likely to come in late June, when the Supreme Court decides whether residents of states that use the federal insurance marketplace have wrongfully been given subsidies to purchase insurance.
If the justices side with the plaintiffs against the Obama administration, they will have done far more to dismantle the Affordable Care Act than the House and Senate budgets. The documents mandate its repeal and include expedited parliamentary rules, called reconciliation, that ensure that legislation to repeal the act cannot be filibustered in the Senate.
Republican leaders in both chambers would move quickly to replace the health care law with a temporary measure that does away with the law's mandates, regulations and tax increases, and then move toward a broader replacement bill. That first effort would probably be vetoed by Mr. Obama, setting the stage, Republicans hope, for bipartisan negotiations over the summer to find a health care alternative.
''That determines when we get to move a robust replacement bill'' for the Affordable Care Act, Mr. Ryan said of the Supreme Court decision.
The most important function of a budget is to set top-line spending limits for military and domestic programs at Congress's discretion, and the House and Senate documents stuck to the strict caps mandated by the Budget Control Act of 2011. But lawmakers in both parties acknowledge that even that prescription might not hold. The president has vowed to veto appropriations bills that abide by those caps, which he says are too severe.
Republicans in both chambers skirted the limit on military spending by moving to put around $40 billion into a war-fighting account that does not count against that cap.
In a duel between possible Republican White House hopefuls, Senator Marco Rubio of Florida moved to raise the Defense Department's core budget without paying for it. He was rebuffed on 68-to-32 vote.
Senator Paul followed suit with an amendment to raise military spending as well, but to pay for it in large part with deep cuts to foreign aid. It was rejected, 96 to 4.
But the pressure is mounting to do more. Defense Department officials say they need relief in the military's training, maintenance and procurement budgets, not in its overseas operations. And even some congressional conservatives say domestic programs like medical research and Homeland Security are badly stretched.
An amendment by Senator Tim Kaine, Democrat of Virginia, called for a lifting of the spending limits, paid for by changes to entitlement programs other than Social Security, a re-examination of other programs and the ending of some tax loopholes. It passed, 50 to 48.
Senate Republicans did set some policy stakes in the ground, some of them surprising. The Senate voted, 54 to 46, to fully repeal the estate tax, even though next year, the value of estates subject to it will have to exceed $5.43 million, or nearly $11 million for a couple. Only about 3,700 estates, or 0.12 percent of the total, were expected to owe any federal estate tax last year.
Republicans helped pass Democratic amendments guaranteeing Social Security and veterans benefits for same-sex couples in states that do not recognize same-sex marriage, and a bipartisan majority voted for federally guaranteed paid sick leave.
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April 10, 2014 Thursday
It's Official: No Deductible Caps in Small-Business Health Plans
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 769 words
HIGHLIGHT: The legislative fix may allow small-business owners to shift some of their health care costs to their workers.
Tucked inside the so-called Medicare "doc fix" bill - must-pass legislation to forestall steep cuts in payments to doctors - that President Obama recently signed was a separate provision that removed restrictions on deductibles in small-business health plans. As a result, small-business owners may be able to shift some of their health care costs, especially as they increase, to their workers.
"Republicans Successfully Chip Away Another Piece of ObamaCare," said the headline of a press release from the office of House Speaker John Boehner. "Repealing this provision will give employers more flexibility over the type of health care options they can offer their employees and will expand the use of high-deductible plans paired with Health Savings Accounts," the press release said. A spokesman for Majority Leader Eric Cantor of Virginia, speaking to Associated Press, called it "another in a series of changes to Obamacare that the House has supported to help save Americans from being harmed by the law."
The Republican victory is largely symbolic, however. The Obama administration had effectively nullified this provision of the Affordable Care Act more than a year ago through regulation.
The Affordable Care Act provision at issue limited the deductibles in small-group health plans to $2,000 for individual coverage and $4,000 for family coverage. Separately, the law also required that small-group plans meet minimum standards for how health care expenses are split between the policyholder and the plan - what is known as actuarial value. The least-generous plans allowed by the law, known as bronze plans, must cover 60 percent of the expenses incurred by a typical group of enrollees.
But it turns out to be very difficult to design a bronze individual plan with a deductible of $2,000 (or, for that matter, a family plan with a deductible under $4,000). As a result, in February 2013, the Health and Human Services Department released final regulations that allowed a plan to have a higher deductible "if that plan may not reasonably reach the actuarial value of a given level of coverage" without it.
"They effectively waived that requirement," said Timothy Jost, a law professor at Washington and Lee University. "They basically said, this doesn't work."
Mr. Jost said that a conflict between two separate provisions in a major law wasn't unusual, but that the partisan paralysis in Washington had made it impossible to fix that sort of mistake in the Affordable Care Act - apparently, that is, until now. "The administration has been forced to deal with it as best they can," he said. "There are a number of things in the statute that the agencies have had to massage."
Kevin Kuhlman, a lobbyist for the National Federation of Independent Business, said the Health and Human Services' regulation was at best provisional. The regulation is due to be revisited in 2016, and there was no guarantee, he said, that the regulation blocking the deductible caps would remain. "This is a significant limiting factor on deductible flexibility in the future," he said. "There are very few ways to mitigate premium increases because of all the new requirements in the law."
Ron Pollack, executive director of Families USA, which lobbied for the health care reform law, agreed that that flexibility would afford small-business owners the opportunity to pass on more of the cost of coverage to employees. "If there's a higher deductible, there's usually a lower premium," he said, "and the small-business owner doesn't pay the deductible." But higher deductibles, he said, may discourage lower-income employees from using their insurance to get care.
Mr. Pollack said that the deductible caps probably kept some business owners from offering plans with deductibles far beyond the limits, even as he acknowledged that the regulation had basically swept the provision aside. "This," he said of the latest action, "opens the door. They don't seem to have to worry about it."
On the other hand, Mr. Pollack held out hope that, despite the continuing rhetoric of repeal, Republicans are coming to terms with the health care law and will work with Democrats to correct its flaws. "They haven't crossed a Rubicon," he said. "They forded a stream. It's a modest, incremental step."
Assessing Who Benefits From the Latest Rulings on the Employer Mandate
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
Ezekiel Emanuel Further Explains His Prediction That Employers Will Drop Health Insurance
An Owner Asks a Question About Offering Employees a Stipend to Buy Health Coverage
Why Employers Will Stop Offering Health Insurance
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November 29, 2013 Friday
Late Edition - Final
Obamacare's Secret Success
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 39
LENGTH: 809 words
The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the ''affordable'' bit wasn't just about subsidizing premiums. It was also supposed to be about ''bending the curve'' -- slowing the seemingly inexorable rise in health costs.
Much of the Beltway establishment scoffed at the promise of cost savings. The prevalent attitude in Washington is that reform isn't real unless the little people suffer; serious savings are supposed to come from things like raising the Medicare age (which the Congressional Budget Office recently concluded would, in fact, hardly save any money) and throwing millions of Americans off Medicaid. True, a 2011 letter signed by hundreds of health and labor economists pointed out that ''the Affordable Care Act contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.'' But such expert views were largely ignored.
So, how's it going? The health exchanges are off to a famously rocky start, but many, though by no means all, of the cost-control measures have already kicked in. Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic.
O.K., the obligatory caveats. First of all, we don't know how long the good news will last. Health costs in the United States slowed dramatically in the 1990s (although not this dramatically), probably thanks to the rise of health maintenance organizations, but cost growth picked up again after 2000. Second, we don't know for sure how much of the good news is because of the Affordable Care Act.
Still, the facts are striking. Since 2010, when the act was passed, real health spending per capita -- that is, total spending adjusted for overall inflation and population growth -- has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn't risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
What could account for this good news? One obvious answer is the still-depressed economy, which might be causing people to forgo expensive medical care. But this explanation turns out to be problematic in multiple ways. For one thing, the economy had stabilized by 2010, even if the recovery was fairly weak, yet health costs continued to slow. For another, it's hard to see why a weak economy would have more effect in reducing the prices of health services than it has on overall inflation. Finally, Medicare spending shouldn't be affected by the weak economy, yet it has slowed even more dramatically than private spending.
A better story focuses on what appears to be a decline in some kinds of medical innovation -- in particular, an absence of expensive new blockbuster drugs, even as existing drugs go off-patent and can be replaced with cheaper generic brands. This is a real phenomenon; it is, in fact, the main reason the Medicare drug program has ended up costing less than originally projected. But since drugs are only about 10 percent of health spending, it can only explain so much.
So what aspects of Obamacare might be causing health costs to slow? One clear answer is the act's reduction in Medicare ''overpayments'' -- mainly a reduction in the subsidies to private insurers offering Medicare Advantage Plans, but also cuts in some provider payments. A less certain but likely source of savings involves changes in the way Medicare pays for services. The program now penalizes hospitals if many of their patients end up being readmitted soon after being released -- an indicator of poor care -- and readmission rates have, in fact, fallen substantially. Medicare is also encouraging a shift from fee-for-service, in which doctors and hospitals get paid by the procedure, to ''accountable care,'' in which health organizations get rewarded for overall success in improving care while controlling costs.
Furthermore, there's evidence that Medicare savings ''spill over'' to the rest of the health care system -- that when Medicare manages to slow cost growth, private insurance gets cheaper, too.
And the biggest savings may be yet to come. The Independent Payment Advisory Board, a panel with the power to impose cost-saving measures (subject to Congressional overrides) if Medicare spending grows above target, hasn't yet been established, in part because of the near-certainty that any appointments to the board would be filibustered by Republicans yelling about ''death panels.'' Now that the filibuster has been reformed, the board can come into being.
The news on health costs is, in short, remarkably good. You won't hear much about this good news until and unless the Obamacare website gets fixed. But under the surface, health reform is starting to look like a bigger success than even its most ardent advocates expected.
URL: http://www.nytimes.com/2013/11/29/opinion/krugman-obamacares-secret-success.html
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The New York Times
March 10, 2017 Friday
Late Edition - Final
White House Raises Doubts on Budget Office
BYLINE: By ALAN RAPPEPORT
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 1103 words
WASHINGTON -- President Trump showed an affinity for ''working the referees'' in his race to the White House, criticizing a federal judge as biased, panning polls as rigged and even questioning the aptitude of the nation's intelligence agencies.
Now, with Mr. Trump's administration aggressively pitching the House Republican plan to repeal and replace the Affordable Care Act, Capitol Hill's official scorekeeper -- the Congressional Budget Office -- is coming under intense fire. As it prepares to render its judgment on the cost and impact of the bill, the nonpartisan agency of economists and statisticians has become a political piñata -- and the latest example of Mr. Trump's team casting doubt on benchmarks accepted as trustworthy for decades.
''If you're looking to the C.B.O. for accuracy, you're looking in the wrong place,'' Sean Spicer, the White House press secretary, said on Wednesday, arguing that the agency's failure to accurately project enrollment in the Affordable Care Act's online marketplaces had essentially killed its credibility.
Mr. Spicer's criticism echoed that of some House Republicans who raised questions this week about the C.B.O.'s record.
The reason for their umbrage is clear: The C.B.O.'s official judgment on the American Health Care Act, as the Republican legislation is known, is expected to be released on Monday and it is more than an intellectual exercise. It could make or break the bill.
Budget rules that Republicans are using to bypass a possible Democratic filibuster in the Senate stipulate that the health care legislation must not add to deficits over the span of a decade. If the C.B.O. predicts that it would, Senate Democrats could block the bill. More broadly, a judgment by the C.B.O. that the Republican plan would strip health care from millions of people could have politically disastrous effects.
Analysts at the Brookings Institution said last Friday that the plan could increase the ranks of the uninsured by more than 15 million -- and said the C.B.O. estimate might put that figure considerably higher.
Created by Congress in 1974, the agency provides forecasts that are the foundation of the budget process. The White House's attack has sparked a fierce backlash among economists, former C.B.O. directors and some lawmakers who see its disparagement as a sign that longstanding legislative traditions are eroding.
The criticism comes after Mr. Trump has expressed skepticism about the validity of unemployment figures from the Bureau of Labor Statistics and amid reports that his economic team has plans to manipulate the calculation of trade data.
To critics of Mr. Trump who say he is in the business of fudging numbers to fit his economic narrative, the jabs at the C.B.O. are particularly worrisome.
''It is a valuable resource for Congress that both parties need,'' said Alice M. Rivlin, the agency's founding director. ''Undermining the credibility of C.B.O. when policy makers need it most harms Congress' ability to do its job and the long-run effectiveness of both political parties.''
But the C.B.O.'s mandate is not ironclad.
Douglas Holtz-Eakin, a conservative economist who led the C.B.O. from 2003 to 2005, also defended its credibility, but he noted that Congress remained the ultimate arbiter if it so chose. While it rarely happens, the Senate Budget Committee could decide to make its own determination about the bill's economic effects.
''In the end, C.B.O. scores are ultimately advisory,'' he said.
Lawmakers have not mused publicly about such a move, which would probably set off a political firestorm. According to Steve Bell, a former Senate Budget Committee staff director in the 1980s, ignoring C.B.O. forecasts for the health bill would dampen hopes for major legislation on taxes or infrastructure because the public would no longer be able to believe government estimates about the cost of such programs.
''Down that path lies serious corruption,'' said Mr. Bell, who now works at the Bipartisan Policy Center.
For its part, the C.B.O. has tried to stay above the fray.
After Newt Gingrich, the former House Speaker and an adviser to Mr. Trump, said this year that the C.B.O. was a ''left-wing, corrupt, bureaucratic defender of big government and liberalism,'' Keith Hall, its Republican-appointed director, defended its work.
''We try very, very hard to be independent and nonpartisan,'' he said at a news briefing in January.
Analysts contend that the C.B.O.'s forecasts for the Affordable Care Act were mixed and that the health law was a challenge because it was such a moving target. A 2015 report by the Commonwealth Fund, which supports health policy research, found that the C.B.O. had overestimated insurance-marketplace enrollment and marketplace costs by about 30 percent and had underestimated Medicaid enrollment by 14 percent.
The missed mark for marketplace enrollments, the report said, stemmed largely from a miscalculation that many employers would drop employee-provided health care and send workers to Affordable Care Act exchanges. They mostly did not.
''The C.B.O.'s projections were closer to realized experience than were those of many other prominent forecasters,'' the report concluded.
In response to questions from Congress last week about its record as a forecaster, the C.B.O. said the cost to the federal government of the Affordable Care Act's insurance-coverage provisions had actually proved to be lower than the agency projected. That was probably because of lower-than-expected enrollment and a slowdown in the growth of health care costs, the C.B.O. said.
Some Senate Republicans argued that the agency's figures should be heeded.
''What matters in the long run is better, more affordable health care for Americans, not House leaders' arbitrary legislative calendar,'' Senator Tom Cotton of Arkansas said in a post on Twitter in which he questioned why the House was considering the bill when the C.B.O. had not scored it.
For their part, Democrats appeared to relish the irony of Republicans assailing an agency whose work they have embraced when it suited their political arguments. That Republicans had appointed Mr. Hall to his post did not go unnoticed.
''I have no idea what the C.B.O. report will say, but I find it amusing that the right-wing Trump administration would try to cast doubt about the integrity of that report when it was the right-wing Republicans who handpicked its director,'' said Senator Bernie Sanders, an independent from Vermont.
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URL: http://www.nytimes.com/2017/03/09/us/politics/cbo-congressional-budget-office-american-health-care-act.html
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February 8, 2017 Wednesday
Late Edition - Final
Issues Facing Republicans in Replacing Health Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 1422 words
WASHINGTON -- Ever since Democrats began pushing the Affordable Care Act through Congress more than seven years ago, Republicans have been trying to come up with an alternative. Candid conversations leaked from a conclave of Republican lawmakers in Philadelphia last month, and public comments since, show they are nowhere near agreement.
The leaked audio recordings revealed that Republicans recognize the technical complexity and political difficulty of the task they have set for themselves: repealing the law known as Obamacare and replacing it with a new plan that, in the words of President Trump, provides ''better health care for more people at a lesser cost.''
What follows is a summary of the thorny questions with which Republicans in Congress are struggling. These are not just academic quandaries. People's lives could depend on the answers. And time is short. Insurance companies have about three months to decide what kinds of health plans, if any, they will sell to the public in 2018.
Many of the choices facing Republicans are variations of a fundamental question: how much of the Affordable Care Act to keep, and how much to discard?
Future of Medicaid
More than half of the 20 million people who gained coverage through the Affordable Care Act did so through Medicaid, the federal-state program for low-income people. Medicaid, begun as an adjunct to the main cash welfare program a half-century ago, has gradually become a pillar of the American health care system, covering more than 70 million people and financing more than 40 percent of all births.
The 2010 health care law, as written by Democrats, required all states to expand Medicaid eligibility. But the Supreme Court said that requirement violated the Constitution by placing ''a gun to the head'' of states. So the expansion became voluntary.
To date, 31 states have expanded Medicaid, and 19, including Florida and Texas, have not. The federal government pays at least 90 percent of the costs for newly eligible beneficiaries. Governors who supported the expansion of Medicaid eligibility, including Republicans like John R. Kasich of Ohio, Rick Snyder of Michigan and Brian Sandoval of Nevada, want to keep it. That would be impossible if congressional Republicans repeal this part of the law, as they tried to do in a budget bill that was vetoed by President Barack Obama last year.
Many who gained coverage under Medicaid are poor adults who were not previously eligible. Republicans in Congress have not decided whether to let states continue such coverage. Nor have lawmakers decided whether additional states will be allowed to expand eligibility, with the same generous contribution of federal funds.
Medicaid is now an open-ended entitlement. Anyone who meets federal and state eligibility criteria is entitled to benefits.
Many Republicans in Congress, including Speaker Paul D. Ryan, would like to roll back the expansion of Medicaid and give each state a fixed amount of money for each beneficiary or a lump sum for all of a state's Medicaid program -- a block grant. Under such proposals, states would have more freedom to set benefits and program rules, but the federal government would probably cut Medicaid spending compared with the amounts projected under current law.
''Governors should be exceedingly wary of block grants'' for the Medicaid program, said former Gov. Steven L. Beshear of Kentucky, a Democrat. If Congress gives states more discretion but less money, he said, ''governors will have to use their enhanced flexibility to make impossible choices -- which individuals to cut from the program, or which benefits to eliminate.''
Pre-existing Conditions
One of the more popular provisions of the Affordable Care Act prohibits insurers from denying coverage or charging higher premiums because a person has a pre-existing condition like cancer, heart disease, diabetes or AIDS. President Trump has said he would like to keep this provision. Many Republicans in Congress agree, but the version they propose is, in some ways, different from the existing law.
Congressional Republicans would provide some protection against discrimination based on pre-existing conditions. To obtain full protection, consumers would need to maintain ''continuous coverage.'' Under some Republican proposals, consumers with chronic illnesses could be charged higher premiums if they had a significant break in coverage lasting, say, more than nine or 10 weeks.
Republicans say this more limited form of protection would provide an incentive for consumers to obtain and maintain coverage. But Democrats say it is unfair because people have gaps in coverage for many legitimate reasons, and they may be unable to pay the premiums needed to maintain it.
Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society, said: ''Research suggests that between 40 percent and 85 percent of cancer patients stop working while receiving cancer treatment, with absences from work ranging from 45 days to six months depending on the treatment. Sometimes they lose their jobs and their employer-sponsored coverage.''
In such cases, he said, patients could be charged ''a premium they cannot afford.''
Representative Greg Walden, Republican of Oregon and chairman of the Energy and Commerce Committee, is drafting a bill to encourage continuous coverage, but said he wanted to make sure that people with pre-existing conditions would always have access to care.
''I've seen cancer up close,'' Mr. Walden said. ''My mother died of ovarian cancer, my sister-in-law of brain cancer.''
Taxes and Fees
One of the biggest questions dividing Republicans is what to do about the taxes and tax increases adopted as part of the Affordable Care Act to help pay for the coverage of millions of low- and moderate-income people.
The new revenue comes from taxes and fees imposed on consumers who go without health insurance; high-income taxpayers; manufacturers of brand-name prescription drugs; makers of certain medical devices; and insurance companies. In addition to an annual fee on insurers, the law imposes a tax on high-cost employer-sponsored health coverage, the ''Cadillac tax'' opposed by labor unions and employers.
Some Republicans, like Senator Bill Cassidy of Louisiana, say the government should keep some of the revenue collected under the Affordable Care Act to help pay for a replacement plan.
By contrast, House Republican leaders and some Republican senators want to eliminate most or all of the taxes. ''After spending seven years talking about the harm being caused by these taxes, it's difficult to switch gears now and decide that they're fine, so long as they're being used to pay for our health care bill,'' said Senator Orrin G. Hatch of Utah, chairman of the Finance Committee.
''All of the Obamacare taxes need to go as part of the repeal process,'' Mr. Hatch said.
Republicans are also divided over a proposal to limit the value of health benefits that employers can provide to employees tax-free. Under current law, employees do not have to pay federal income tax on contributions that employers make to their health insurance. House Republicans say this tax break amounts to an open-ended subsidy for employer-sponsored insurance, encouraging employers and employees to choose more expensive coverage than they otherwise would.
Mr. Ryan reaffirmed his support for limiting the tax break last week, but said that whether Congress would approve the change ''was an open question.''
Transition and Timing
Several other questions vex Republicans as they try to write a replacement. How will they ensure a smooth transition to the market-oriented health care system they want to create? How much time should elapse between the passage of a repeal bill and its effective date?
If the federal government spends tens of billions of dollars to subsidize the purchase of health insurance, will it set standards for that insurance? Will it still require insurers to cover maternity care, mental health services and treatment for drug abuse?
Should Congress cut off funds for Planned Parenthood clinics, which receive Medicaid money for birth control, cancer screenings, treatment of sexually transmitted diseases and many other services? Mr. Ryan has said that federal funds for Planned Parenthood would be cut off in a repeal, but some Republicans say that would be a political mistake.
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URL: http://www.nytimes.com/2017/02/07/us/politics/affordable-care-act-trump-republicans.html
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GRAPHIC: PHOTO: Speaker Paul D. Ryan, at a news conference Tuesday with House Republicans, would like to roll back the expansion of Medicaid. (PHOTOGRAPH BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES)
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July 24, 2013 Wednesday
The New Economics of Part-Time Employment, Continued
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 858 words
HIGHLIGHT: A new proposal to redefine part-time work in the Affordable Care Act would heighten disruption of the labor market, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
A revised definition of part-time employment may have some popular appeal, but it will not repair the Affordable Care Act's disincentives for full-time employment or its extra costs for taxpayers.
Part-time employment rarely includes health benefits. The lack of health benefits and the lower pay for part-time work have traditionally discouraged people from taking part-time jobs rather than full-time jobs, but both of those attributes of part-time jobs are about to change.
I explained in an earlier post how, in many cases, the Affordable Care Act would almost entirely eliminate these two shortcomings of part-time employment by offering access to generously subsidized health insurance to part-time employees while denying it to most people who work full time. As a result, more people will work part time (under the law, less than 30 hours a week) rather than full time, and this will occur at significant taxpayer expense.
Two senators, Joe Donnelly, Democrat of Indiana, and Susan Collins, Republican of Maine, are proposing to tweak the Affordable Care Act by changing the definition of part-time work to include any work schedule of 39 hours a week or less. They say the change conforms with traditional definitions of full-time work and will prevent workers from having their work schedules cut.
Their proposal is likely to have the opposite effect. Although it may be true that their proposal would prevent cuts in hours for those now working, say, 35 hours a week, it would be likely to cause cuts for employees working 40 to 45 hours a week, because staying short of the 40-hour threshold would be closer to their current work schedule than staying short of the law's 30-hour threshold.
More important from an economic point of view, the 40-hour threshold would further magnify the already strong disincentives for working full time. The table below illustrates what may happen.
The left column of the table shows the economics of a full-time position (40 hours a week). Between employer health insurance premiums and the employee paycheck, this position costs the employer $56,000 a year, or about $28 an hour. The full-time employee's pay after his portion of health insurance premiums are withheld is $42,000.
Although covered by health insurance, the employee and his family incur $3,000 in additional health costs from health insurance deductibles, co-payments and so on ($3,000 is typical for a family of four with a comprehensive health plan). The employee also has work expenses for commuting, child care and so on, which I assume to be $100 a week when working full time.
The part-time columns of the table show two situations for a part-time position with the same employer cost an hour of $28. The middle column is the situation I discussed earlier, in which the full-time threshold is the 30 hours contained in the law. The right column is the situation that would apply if Senator Donnelly and Senator Collins have their way and workers become part-time by cutting their weekly hours to 39.
Because the part-time position is 39 hours a week, the annual employer cost is $54,600. All of the $54,600 consists of cash compensation for the employee, because the part-time position does not include health insurance.
The part-time employee has to pay for his own health insurance, but the new law limits his premiums to $3,947 (the law pays the other $8,463 from the Treasury) and limits his out-of-pocket health costs to $4,590 (the law pays the other $510; by design the law increases deductibles and co-payments but uses subsidies to offset those increases for low- and middle-income families).
Net of work expenses ($100 a week for both 40- and 39-hour positions) and health expenses, the 39-hour position pays $41,063, significantly more than the full-time position's $34,000.
By taking a 39-hour position, the employee can have comprehensive health insurance coverage and actually make more money than he would in a full-time position. In effect, the new subsidies totaling almost $8,973 more than fully offset, from the point of view of employers and their employees, the loss of production that occurs from working 39 hours a week rather than 40.
It's one thing for public policies to present workers with a small reward for working full time. But the proposal from the two senators would put millions of people in the position of having to pay - in the form of less disposable income - for the privilege of working full time. When millions of workers choose part-time rather than full-time work under the Donnelly-Collins proposal, it will be taxpayers who pick up the tab.
The Affordable Care Act is full of disincentives. But tweaking the law without carefully considering incentives is likely to increase the law's damage to the labor market and its depletion of taxpayer funds.
A Surge in Part-Time Workers
What Job-Sharing Brings
Working Parents, Wanting Fewer Hours
Yes, the Sequester Is Affecting the Job Market
The New Economics of Part-Time Employment
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(First Draft)
May 21, 2015 Thursday
Republicans' Plan to Replace Health Law Is ¯\_([#x30c4])_/¯ , Senator Says
BYLINE: ROBERT MACKEY
SECTION: US; politics
LENGTH: 254 words
HIGHLIGHT: Senator Chris Murphy, Democrat of Connecticut, introduced a popular Internet symbol for a careless shrug of the shoulders — ¯\_([#x30c4])_/¯ — into the Congressional record to describe the Republican Party’s position on the Affordable Care Act.
At precisely 3:56 p.m. on Thursday, Senator Chris Murphy, Democrat of Connecticut, introduced a popular Internet symbol for a careless shrug of the shoulders - ¯\_([#x30c4])_/¯ - into the Congressional record, holding it up on a placard and describing it as "a pretty good summary of what the Republicans' plan is," if the Supreme Court strikes down the Affordable Care Act this summer.
pic.twitter.com/JBSapgJjs2
- Howard Mortman (@HowardMortman) May 21, 2015
Pointing to the symbol, known as a shruggie, Mr. Murphy suggested that "the Republicans' plan if King v. Burwell goes in favor of the plaintiffs is essentially a shrug of the shoulders."
As Kyle Chayka explained in a post for The Awl last year, "The shruggie or 'smugshrug,' as it is sometimes called, is what's known as a 'kaomoji,' or 'face mark' in Japanese. It's similar to an emoji or emoticon, but it incorporates characters from the katakana alphabet, instead of underscores and carets, for a wider range of expression."
The symbol of a "lopsided, grinning face with upturned palms," Mr. Chayka added, "is fundamentally connected to the experience of being online, in part because it cannot be spoken, only acted or typed." And, like learning a new word, once you learn the meaning of the symbol, it does seem to be everywhere on the Internet.
It was the ¯_([#x30c4])_/¯ of times, it was the ¯_([#x30c4])_/¯ of times.
- Kevin Nguyen (@knguyen) May 13, 2014
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The New York Times
July 19, 2016 Tuesday
Late Edition - Final
Obama on Obamacare's Flaws: An Assessment
BYLINE: By REED ABELSON and MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 3
LENGTH: 1023 words
President Obama has published an essay on Obamacare in The Journal of the American Medical Association. While it hit a lot of the Affordable Care Act's high points, it was also pretty frank that the health law has some weaknesses that need to be fixed. Margot Sanger-Katz and Reed Abelson, two New York Times reporters who have been covering Obamacare, discuss the policy changes that the president wants.
Margot: Were you surprised by his acknowledgment of problems? I know I was.
Reed: I thought he was pretty realistic in talking about the need to make various fixes to the law. That's been an issue since it was passed in 2010. There is a fairly broad consensus that the law could be changed to make it work better, even among its supporters. What did surprise me was the president's admission that affordability remains a real concern for many people, even with subsidies.
Margot: But the president wasn't talking about little tweaks. I feel that he recommended at least two pretty substantial policy changes. The idea of offering more subsidies to buy health insurance has been talked about before, but certainly not by the Obama administration. His essay seems like a real acknowledgment that health insurance still isn't affordable enough for some people. We've talked before about hearing from higher-income people who still can't afford health insurance. Between premiums and deductibles, some people are spending more than 25 percent of their incomes on care, according to an Urban Institute report.
Reed: Some of that problem with high prices was supposed to be solved by more competition among health insurance companies. Which gets to the second important change, I think: adding a Medicare-like public plan in areas of the country where there remain too few companies offering plans on the state marketplaces. (I notice the president didn't dwell on the increasing number of failures among the co-ops, the nonprofit insurers created by the law to serve as something akin to the so-called ''public option.'')
The fact that the president admitted that the law had not succeeded in increasing competition everywhere was an important concession. But what do you think of the idea of having a government-operated plan compete along with private insurers, something along the lines of what Medicare does today with the private Medicare Advantage plans?
Margot: I think the public option was definitely the biggest headline out of the president's piece. And it's interesting to see so many Democrats converge around this policy idea, which was talked about when the Affordable Care Act was being written, but was ultimately axed from the law because of lack of support. Hillary Clinton just came out strongly for something similar over the weekend, though she's expressed milder support before. And Bernie Sanders was also cheering for a public option during his Clinton endorsement speech Tuesday. Seems like a real shift leftward for two out of three of them. Considering that a public option has almost no chance of passing in Congress, it's unclear why it is having such a moment. I guess it's a good political halfway point between Obamacare as it exists, and a single-payer system, which excites a lot of Democratic voters.
But even if it didn't have political problems, do you think a government health plan could work the way the president described it? His essay said that it would become a sort of fallback, operating only in places where competition is limited. It's hard to imagine a public plan that jumps in and out of the market in places every year.
Reed: I confess I have a hard time envisioning a government plan available in only certain places. Traditional Medicare is always an option everywhere. A lack of competition is a signal that the economics don't work for a private insurer in a given geographic area, and I'm not sure how a public option in those markets changes things, although it does offer someone more choice. Another possibility would be that you could increase subsidies for those areas or try other ways to make it more attractive for insurers to sell policies in those markets.
Margot: When you talk to people who advocate a public option, the theory is that it'll help keep insurers honest by providing some competition from low-cost plans. But I wonder how that will work in practice. One big advantage that a Medicare-like plan might have is the ability to pay less to doctors and hospitals than many commercial plans. But if the public option is really able to underprice the private options by a lot, why would they stay in the market?
Reed: When it was first floated, the insurers objected because they simply don't have the pricing power of Medicare, which essentially dictates prices rather than negotiates with hospitals and doctors. They thought it was a path to single-payer because it would eventually drive all of them from the market. Maybe Bernie Sanders would approve, but I'm not sure there is any real political support for the idea. Karen Ignagni, who was the chief executive of the trade association representing the insurers, argued at the time that if we wanted a government-run system, we should have that discussion.
Still, Congress's current position of just saying, ''No, let's overturn the law,'' hasn't helped fix any of the shortcomings that exist.
An area where I thought the president might be giving the law too much credit was in saying the law had managed to successfully control costs and improve quality. What do you think?
Margot: Cost control is one of those great unanswered questions in health policy. There are many theories about what is going on. But nearly all of the rigorous analyses say that Obamacare gets, at best, partial credit for why health spending growth has been slow. I can see why the president might want to congratulate himself for this welcome trend. But I think he's on firmer ground touting a reduced uninsured rate than cost control as the legacy of Obamacare.
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URL: http://www.nytimes.com/2016/07/14/upshot/obama-on-obamacares-flaws-an-assessment.html
LOAD-DATE: July 19, 2016
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GRAPHIC: PHOTO: President Obama at an event in June. In a recent essay, he acknowledged shortcomings of the Affordable Care Act. (PHOTOGRAPH BY ZACH GIBSON/THE NEW YORK TIMES)
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(Taking Note)
April 24, 2014 Thursday
More 'Pinocchios' for the Koch Brothers
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 561 words
HIGHLIGHT: New ads from Americans for Prosperity deliberately twist the truth about health-care reform.
The health care ads being run by Americans for Prosperity - one of the many frantically waving arms of the Koch brothers - are a gift to fact checkers everywhere. Because they deliberately twist the truth to persuade people to "stop supporting Obamacare," they have become a machine for producing "Pinocchios," the mendacity rating system used by Glenn Kessler at The Washington Post.
In today's installment, Mr. Kessler gave two Pinocchios (out of four) to three A.F.P. ads that went up this week. He dinged the ad below for falsely claiming that health insurance premiums are up by 90 percent in New Hampshire.
And he criticized this series of ads for suggesting that hundreds of thousands of people in Michigan and Colorado lost their insurance because of the Affordable Care Act, without pointing out that many of those policies were later extended or renewed.
Those Pinocchios are fine as far as they go. But since this is an editorial-page blog, we can go a little further than Mr. Kessler and toss many more long noses at the Koch ads. (Does this dial go to 11?)
What's truly erroneous about all these ads (the full series of which is available on the A.F.P. website, if you have the fortitude) isn't so much what they say as what they never say. They give viewers the impression that all the pre-existing problems with the health insurance system are the fault of Mr. Obama's law, never bothering to explain how bad things have been for decades.
For example, it's true that health insurance premiums will be going up for some people under the new system, in most cases because they will have better coverage. But premiums for private insurance have been rapidly escalating for years, far beyond inflation. Since 2003, they went up by 80 percent, according to the Kaiser Family Foundation, nearly three times as fast as wages and inflation. And the ads never mention the millions who will now get insurance coverage for free or extremely low cost because of the program's subsidies. Those people aren't the Kochs' intended audience.
Similarly, insurance companies used to routinely cancel individual policies, sometimes because the policy holders got sick, or because the companies decided not to do business in a state or region anymore. They can't do that now. But the ads never mention that, instead falsely suggesting that vast numbers of ordinary people have been left without coverage because of the law.
As Politico reported yesterday, a new study says that millions of the so-called "cancelled" policies under the Affordable Care Act (which were actually policy upgrades) would have been cancelled anyway by the policyholders. Most people who have individual policies don't keep them for longer than a year, either because they join a new employer's plan or change their own policies.
That's the kind of context you will never get in a Koch ad, whether or not the texts of the ads are literally correct. The billionaires behind this effort are on a crusade to end Democratic control of the Senate and ultimately to discredit the idea that government can improve people's lives through a social program. Context just gets in their way.
The Birth of a Conspiracy Theory
Facts & Figures: A Cheaper 'Obamacare'
Kathleen Sebelius Was Too Cool and Too Patient
No Comment Necessary: Replacing the A.C.A. With...the A.C.A.?
Facts & Figures: Clueless on the 'Obamacare' Deadline
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March 20, 2015 Friday
Late Edition - Final
Poll on Health Care Law Shows Increased Support After Smooth Enrollment Period
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 615 words
WASHINGTON -- The gap between Americans who view the Affordable Care Act favorably and those who do not is smaller now than at any time since the fall of 2012, a year before the law's disastrous rollout, according to a monthly poll that has tracked attitudes about the polarizing law since President Obama signed it five years ago.
The latest Kaiser Health Tracking Poll, conducted in early March by the Kaiser Family Foundation, a nonpartisan health policy research group, found that 43 percent of respondents had an unfavorable opinion of the law, while 41 percent viewed it favorably. Though more Americans continue to reject the law than embrace it, the margin has narrowed considerably even since last July, when 53 percent viewed it unfavorably in the Kaiser poll and 37 percent viewed it favorably.
Drew Altman, the foundation's president, noted that the near closing of the gap had happened after a three-month open enrollment period that involved few technological problems, and at a time when the law is not being as bitterly debated in Washington and in the states as it has been in the past.
''It reflects the fact that the last several months have not been a time when, compared to the past, the Affordable Care Act has been under sharp political attack,'' Mr. Altman said.
Forty percent of respondents said they would like to see Congress repeal or scale back the law, while 46 percent said they would prefer that Congress move forward with carrying out the law or expand what it does. Still, Mr. Altman noted, most Republicans continue to oppose the law, and most Democrats continue to favor it. ''Opinion on the A.C.A. is still stuck in an intractable partisan divide,'' he said.
The poll also found that a majority of respondents were worried about the potential impact of a case before the Supreme Court that could limit health insurance subsidies available under the law to people in states that run their own online marketplaces. Sixty-two percent said such a ruling would have a negative impact on the country, while 23 percent said the impact would be positive.
Nearly 80 percent said they were not confident that Republicans in Congress and Mr. Obama could work together to resolve the issues created by a ruling against the subsidies, which would block them for people in more than 30 states. Regardless, 81 percent of Democrats and 67 percent of independents said that in the event of such a ruling, Congress should pass a law allowing people in those states to continue receiving subsidies. Most Republicans, 56 percent, said Congress should take no action.
But in the potentially affected states, even Republicans said those states should create their own marketplaces so that their residents could keep receiving subsidies. About 60 percent of Republicans, 70 percent of independents and 80 percent of Democrats in states that could be affected by the ruling said they favored state action if the Supreme Court sided with the plaintiffs in the case, King v. Burwell.
The poll also found that public awareness of the case remains dim, with more than half of respondents saying they had heard nothing about it and another 25 percent saying they had heard only a little.
Still, Mr. Altman said, ''when we explain the issue to them, I think it's just a matter of common sense or fairness: They don't get why people in some states should get financial help from the government but people in other states would not get it.''
The nationwide tracking poll of 1,503 adults was conducted March 6 to 12 using cellphones and landlines. Interviews were in English and Spanish. The margin of sampling error was plus or minus three percentage points for the full sample.
URL: http://www.nytimes.com/2015/03/20/us/poll-on-health-care-law-shows-increased-support.html
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December 3, 2013 Tuesday
Late Edition - Final
A New Wave Of Challenges To Health Law
BYLINE: By SHERYL GAY STOLBERG; Richard Pérez-Peña contributed reporting from South Bend, Ind.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1165 words
WASHINGTON -- More than a year after the Supreme Court upheld the central provision of President Obama's health care overhaul, a fresh wave of legal challenges to the law is playing out in courtrooms as conservative critics -- joined by their Republican allies on Capitol Hill -- make the case that Mr. Obama has overstepped his authority in applying it.
A federal judge in the District of Columbia will hear oral arguments on Tuesday in one of several cases brought by states including Indiana and Oklahoma, along with business owners and individual consumers, who say that the law does not grant the Internal Revenue Service authority to provide tax credits or subsidies to people who buy insurance through the federal exchange.
At the same time, the House Judiciary Committee will convene a hearing to examine whether Mr. Obama is ''rewriting his own law'' by using his executive powers to alter it or delay certain provisions. The panel also will examine the legal theory behind the subsidy cases: that the I.R.S., and by extension, Mr. Obama, ignored the will of Congress, which explicitly allowed tax credits and subsidies only for those buying coverage through state exchanges.
''We have agencies under this administration having an attitude that they can fix a statute, that they can improve upon a statute, that they can look at a statute's clear language and disregard it,'' Scott Pruitt, the Oklahoma attorney general, who is bringing one of the cases, said in an interview Monday. ''The president himself has said on more than one occasion, 'I can't wait on Congress.' In our system of government, he has to.''
The subsidy lawsuits grow out of three years of work by conservative and libertarian theorists at Washington-based research organizations like the Cato Institute, the American Enterprise Institute and the Competitive Enterprise Institute. The cases are part of a continuing, multifaceted legal assault on the Affordable Care Act that began with the Supreme Court challenge to the law and shows no signs of abating.
''After the A.C.A. was enacted and after the president signed it, a lot of people -- me included -- decided that we weren't going to take this lying down, and we were going to try to block it and ultimately either get the Supreme Court to overturn it or Congress to repeal it,'' said Michael F. Cannon, a health policy scholar at the libertarian-leaning Cato Institute, who helped develop the legal theory for the subsidy cases and will testify in the House on Tuesday.
On Monday, the Supreme Court refused to hear a challenge brought by Liberty University, a Christian college in Virginia, to the ''employer mandate,'' which requires companies with more than 50 employees to offer coverage. In another challenge, the Pacific Legal Foundation, a conservative group, has filed suit claiming that the law is unconstitutional because it was introduced in the Senate, not the House, where tax bills must originate.
The law has also spawned a separate raft of religious freedom cases over its requirement that employers provide insurance coverage for contraception to their workers. The University of Notre Dame plans to file suit on Tuesday challenging an Obama administration rule that exempts religious employers like churches, but not nonprofits, like schools, which may cover contraception through third-party administrators. The Supreme Court agreed last week to hear a pair of similar suits from commercial corporations.
Jonathan Adler, a law professor at Case Western Reserve University and Mr. Cannon's writing partner, predicts the act will be the subject of lawsuits for years.
''Among critics of the law there is a feeling that the law doesn't have the same legitimacy as a law that passed with bipartisan support,'' he said.
The subsidy cases, if successful, would strike at the foundation of the law. Subsidies and tax credits, which could be available to millions of low- and middle-income Americans, are central to Mr. Obama's promise of affordable care. In drafting the law, Congress wrote that such financial help would be available to people enrolled ''through an exchange established by the state'' under the law.
But since passage of the Affordable Care Act in March 2010, the vast majority of states -- roughly three dozen -- decided not to set up their own exchanges, in part because many Republican governors opposed the law. That has left HealthCare.gov, the online federal insurance exchange, to handle the bulk of enrollment requests.
If courts rule that customers cannot get subsidies through the federal exchange, it would ''make the HealthCare.gov problems look like a hiccup,'' Mr. Cannon said.
The House hearing, titled ''The President's Constitutional Duty to Faithfully Execute the Laws,'' will focus largely on the Affordable Care Act. Representative Robert W. Goodlatte, Republican of Virginia and chairman of the committee, argues that Mr. Obama has ''changed key provisions in Obamacare without congressional approval,'' through executive actions, like delaying the employer mandate for one year.
Aides to Mr. Obama say the president offers a legal rationale with each administrative decision, and legal experts say judges ordinarily give agencies like the I.R.S. broad latitude in interpreting federal law. An administration official, speaking on condition of anonymity to discuss pending litigation, defended the I.R.S. interpretation.
''Our position, at bottom, is that when Congress enacted the Affordable Care Act, it was creating a national solution to a national problem,'' the official said.
Tim Jost, a law professor and health policy expert at Washington and Lee University, agreed, saying that by including a ''federal fallback exchange'' in the law, Congress clearly intended to extend tax credits to users of HealthCare.gov.
The seeds of the subsidy cases were planted as far back as December 2010, when Thomas P. Miller, a scholar at the American Enterprise Institute, convened a forum to explore legal avenues to undo the health law. By spring 2012, even before the Supreme Court had ruled on the constitutional challenge to the ''individual mandate'' -- the requirement that nearly all Americans purchase insurance or pay a fine -- Mr. Miller said he approached Sam Kazman, general counsel of the Competitive Enterprise Institute, about finding plaintiffs.
One plaintiff in the District of Columbia case, David Klemencic, the sole owner of a carpet and flooring store in the town of Ellenboro, W.Va., was also a plaintiff in the constitutional challenge to the individual mandate. In an interview, Mr. Klemencic, who does not have any employees, said he had deep, philosophical objections to any effort by the government to require him to purchase insurance, and would refuse to accept a subsidy even if eligible.
''I go to the doctor now, I go to the dentist now, I take my checkbook and I pay for it,'' he said. ''If I'm forced into some sort of program where it's subsidized by the government, I won't go see a doctor.''
URL: http://www.nytimes.com/2013/12/03/us/politics/a-new-wave-of-challenges-to-health-law.html
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November 21, 2013 Thursday
The G.O.P.'s Health Reform Playbook
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 534 words
HIGHLIGHT: House Republicans have been organizing their strategy behind closed doors for the last month.
The last thing Republicans want right now is to repeal the Affordable Care Act.
They may claim it is destroying the country, but they need it, and desperately, to rebuild their party. They even have a detailed playbook to exploit it, outlining how and when to stage attacks against Democrats who support it in order to inflict maximum damage in the months before the 2014 midterm elections.
As Jonathan Weisman and Sheryl Gay Stolberg reported in this morning's Times, House Republicans have been organizing their strategy behind closed doors for the last month. They began by capitalizing on the gifts given them by the White House in the form of the malfunctioning health care website and President Obama's false promise that no one need lose an insurance policy. Then they moved on to claims that personal data is insecure on the insurance exchanges.
Next, according to the playbook, will come criticism of premium price hikes, and breast-beating about changes to Medicare Advantage plans, as well as the possibility that people will lose their doctors under some policies.
Republicans will also hold hearings, and come armed with anecdotes from outraged citizens who suddenly find their new health insurance options aren't perfect.
Reform has given new life to a party that was in the depths after the shutdown debacle just last month.
This deep concern about Americans' access to quality insurance is entirely new and utterly insincere, of course. Nearly one in 10 people on Medicare - 4 million people - are dissatisfied with that program, according to surveys, but you don't hear their complaints broadcast at hearings or at Republican news conferences. In 2010, long before the health reform law took effect, 20 percent of people on employer-based insurance expressed dissatisfaction with their plans, as did a third of people on the individual market. They complained about high deductibles and constrained networks of doctors and hospitals, just as many of them will under the new system. And they complained about cancelled policies.
Republicans never cared about those concerns before the Affordable Care Act came around, and they don't really care now, even though they're doing a great job of feigning outrage. They're simply using these grievances, magnified by anecdotal media coverage, to batter Democrats who are still standing up for the president's program.
Some of those Democrats are fighting back. They're pointing out, as the White House did yesterday, that the growth in health care costs is slowing significantly. They're trying to highlight people who are saving money on their new policies, or who can buy insurance even if they are sick. And they will try to broadcast the voices of the previously uninsured, who have never appeared in a Republican diatribe and never will.
But the most attention, as always, will be paid to the shrillest critics. Just remember, as their attacks pick up in volume in the months to come, that they were prepared long in advance, as cheap as canned laughter.
How the Shutdown May Hurt the Environment
House Republicans Should 'Knock it Off'
The President Fumbles the Court Issue
Talking Health Insurance Over Thanksgiving Dinner
No Budget, Because HealthCare.gov
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February 6, 2017 Monday
Late Edition - Final
Trump Extends Timetable for New Health Law
BYLINE: By MARK LANDLER
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 439 words
WEST PALM BEACH, Fla. -- President Trump said in an interview that aired on Sunday that a replacement health care law was not likely to be ready until either the end of this year or in 2018, a major shift from promises by both him and Republican leaders to repeal and replace the law as soon as possible.
''Maybe it'll take till sometime into next year, but we're certainly going to be in the process,'' Mr. Trump said during an interview with Bill O'Reilly of Fox News, after Mr. O'Reilly asked the president whether Americans could ''expect a new health care plan rolled out by the Trump administration this year.''
''It statutorily takes awhile to get,'' Mr. Trump said. ''We're going to be putting it in fairly soon, I think that, yes, I would like to say by the end of the year at least the rudiments but we should have something within the year and the following year.''
Mr. Trump acknowledged that replacing former President Barack Obama's Affordable Care Act is complicated, though he reiterated his confidence that his administration could devise a plan that would work better than the law -- despite having provided few details of how such a plan would work.
''You have to remember Obamacare doesn't work, so we are putting in a wonderful plan,'' Mr. Trump said.
Speaker Paul D. Ryan has vowed to move legislation for a replacement for the Affordable Care Act by the end of March. But some Republicans are worried about a political backlash if they repeal the law without an adequate replacement -- potentially throwing millions of people off their insurance -- and have urged a more methodical approach.
Senator Lamar Alexander of Tennessee, a Republican who is the chairman of the Senate Committee on Health, Education, Labor and Pensions, recently proposed repairing parts of the health care law ahead of scrapping the whole package.
Mr. Trump said last month that he wanted to present a replacement soon after the Senate confirmed his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia. The Senate is scheduled to vote on Mr. Price's confirmation this week.
''We're going to be submitting, as soon as our secretary is approved, almost simultaneously, shortly thereafter, a plan,'' Mr. Trump said in January.
Last month, the president signed an executive order to begin unwinding the Affordable Care Act. It gave the Department of Health and Human Services the authority to ease what it called ''unwarranted economic and regulatory burdens'' from the existing law.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/02/05/us/politics/donald-trump-health-care-law-repeal-replace-plan.html
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(In Practice)
September 30, 2013 Monday
Picking a Plan and a Cobra Choice
BYLINE: Tara Siegel Bernard
SECTION: US
LENGTH: 304 words
HIGHLIGHT: Questions are rolling in about the new health insurance marketplaces under the Affordable Care Act. Your Money columnist Tara Siegel Bernard tackles a couple.
At least one thing is certain about the new health insurance marketplaces under the Affordable Care Act: consumers have a lot of questions.
My latest "Your Money" column covered many of the basics. This week, I'm answering readers' questions. If you're not sure how the law affects you and your family, e-mail your question to tsbernard@nytimes.com
Q. Who can help me pick the right plan?
A. There are already reports of con artists trying to deceive consumers, so don't trust just anyone. Trained navigators, application assisters and certified application counselors can help you with questions. They can be found through HealthCare.gov.
Insurance brokers and representatives can also help, but are not required to tell you all of your options, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.
Q. I haven't seen a clear statement as to whether being on Cobra (from prior coverage on my ex-wife's employer plan) will exclude me from the exchanges. Or, can I drop the Cobra plan if there's a better deal on the exchange?
A. If you lose your job, you may be able to extend your employer-based health insurance for up to 18 months through Cobra. (But you often must pay the entire premium - that is, the share you paid when you were employed, plus your employer's share.)
If you have Cobra coverage, you can keep it. But you also can go to the exchange. In addition, you may qualify for subsidized coverage. You can get exchange-based coverage as early as Jan. 1, as long as you enroll in a plan by Dec. 15.
Problems at Health Care Web Site Not From Online Attack, Experts Say
Readers Ask About Subsidies and Other Health Care Law Provisions
Closer Look at Polls Finds Views of Health Law a Bit Less Negative
Federal Data Reveals Variety of Health Care Plans
Employees Without Health Care Coverage Looking to Exchanges
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(Taking Note)
April 18, 2016 Monday
Obamacare's Striking Effect on America's Least Fortunate
BYLINE: VIKAS BAJAJ
SECTION: OPINION
LENGTH: 351 words
HIGHLIGHT: The legislation has helped many of the least privileged people in the country get health insurance.
Republican lawmakers, particularly in the House and in state governments, have been adamantly opposed to the Affordable Care Act, the 2010 health reform law often referred to as Obamacare. Perhaps that's because the legislation has helped millions of poor people, minorities and immigrants get health insurance.
An analysis of Census data by the Times reporters Sabrina Tavernise and Robert Gebeloff shows striking gains for many of the least privileged people in the country under the health reform law. For example, about 67 percent of Hispanics had health coverage in 2014, an increase of 7.2 percentage points from 2013. Native Americans, blacks, Asian Americans, high-school graduates and legal immigrants all saw big gains in coverage, too.
These are major gains and should be celebrated, especially considering the fact that the proportion of Americans who did not have health insurance had been rising for many years before the health reform law. Reversing that trend will undoubtedly be one of the most important parts of President Obama's legacy. And the gains in coverage have been achieved at a much lower cost than anticipated. Last month, the Congressional Budget Office said the total cost of health reform is about 25 percent less than the office had forecast when the law was signed.
Yet Republicans lawmakers remain deeply opposed to the legislation - the House of Representatives has voted dozens of times to repeal the law in a fruitless display of pique. And 19 Republican-controlled state governments still refuse to expand their Medicaid programs even though the federal government will pay the vast majority of the cost of covering more people under that program. Their failure to expand Medicaid is depriving millions of people of health insurance. In 2014, about 33 million Americans, or 10.4 percent of the population, were uninsured, according to the Census Bureau.
Of course, the Affordable Care Act is not perfect - too many people still do not have coverage and the cost of insurance and deductibles remain a big problem for many people. But the law is working as it was meant to.
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(Economix)
July 5, 2013 Friday
A Surge in Part-Time Workers
BYLINE: ANNIE LOWREY
SECTION: BUSINESS; economy
LENGTH: 247 words
HIGHLIGHT: The June jobs report saw a surge in part-time workers, and the health care law that starts coming into full effect next year might be in part responsible.
The June jobs report saw a surge in part-time workers, and the health care law that starts coming into full effect next year might be in part responsible. The number of part-time workers for economic reasons climbed to 8.2 million in June from 7.6 million in March.
The economist Casey B. Mulligan ran through the numbers on this blog earlier in the week. The Affordable Care Act gives employers an incentive to hire part-time workers rather than full-time workers, as they might be compelled to offer health coverage to the latter, but not the former. That's why a number of big employers have started offering more temporary or part-time positions.
It also makes part-time jobs more attractive for workers. Say you currently have a 20-hour-a-week job with no health coverage, and that you cannot afford to buy insurance on the private market. Soon, the government will start offering you generous subsidies to buy a plan on the new health care "exchanges" - meaning, provided your income is low enough, you get an expensive benefit with taxpayers picking up most of the tab.
Granted, the Obama administration announced this week that it is delaying for one year a rule requiring big employers to cover their full-time workers or pay a penalty - that might also delay some of the shift from full-time to part-time work.
What Job-Sharing Brings
The New Economics of Part-Time Employment
The Rise of Part-Time Work
Putting Off the Employer Mandate
Confusing the Public on the Affordable Care Act
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(DealBook)
August 20, 2012 Monday
Investors in Health Care Seem to Bet on Incumbent
BYLINE: ANDREW ROSS SORKIN
SECTION: BUSINESS
LENGTH: 878 words
HIGHLIGHT: Despite public support for Mitt Romney, many businessmen and investors are wagering more than rhetoric on President Obama.
Who is going to win the presidential election?
You might want to ask Mark T. Bertolini. He just bet $5.7 billion on President Obama.
Mr. Bertolini is the chief executive of Aetna, which on Monday agreed to acquire Coventry Health Care, a huge provider of Medicare and Medicaid programs. His $5.7 billion bet makes a lot of sense if you believe that the Affordable Care Act - otherwise known as Obamacare - will not be repealed.
Mitt Romneyhas pledged to repeal the act "on my first day if elected," so any gamble that Obamacare stays intact could be fairly described as a wager that President Obama will remain in office.
At a time when so many in the business community appear to be supporting Mr. Romney, it is telling that some businessmen and investors expect a different result - and are wagering more than rhetoric; they are staking their wallet on it.
It may be counterintuitive, but with the Standard & Poor's 500 up 9.5 percent in the last three months and the stock market over all at its highest point since the financial crisis, there is an argument to be made that investors writ large may be helping the incumbent to win. Intrade, an online market that allows investors to bet on political outcomes and other world events, shows that President Obama is favored to win, 57.3 percent to 42 percent.
"The best single predictor of presidential re-election results that we found was the percentage change in the stock market during the three years that preceded Election Day," Deepak Goel of the Socionomics Institute said in February when he released a study that was recently highlighted by Reuters. The study said that recent performance of the stock market was more important than gross domestic product, inflation and unemployment.
At a minimum, the stock market, which is an indicator of future earnings, seems to be in disagreement, at least somewhat, with the steady drumbeat of C.E.O.'s and investors who have said that President Obama's administration, in the words of Daniel Loeb, the outspoken activist hedge fund investor, "is openly hostile to most businesses and unable to articulate or implement policies to spark growth and reduce unemployment."
Mr. Loeb is a frustrated Obama voter who now backs Mr. Romney.
But take a look at some of his most recent investments in the health care field. In the last quarter, he reported in Securities and Exchange Commission filings, he picked up shares of Aetna, Cigna, Humana, UnitedHealth and WellPoint, among others. All of those companies stand to benefit while Obamacare remains in force; a repeal of the bill could send those shares reeling.
Mr. Bertolini of Aetna insisted on Monday that the deal was not dependent on who wins the White House. But he has to say that. If he believed Mr. Romney was going to win and he still wanted to buy Coventry, he would have waited until after the election and bought it at a sharp discount.
In a note to investors on Monday about Aetna's Coventry deal, an analyst at Barclays explained the rationale of it plainly as a way of "strategically positioning themselves to capitalize on further gains which may arise as a result of the election and health care reform."
Aetna is not the only company to make a bet on the White House. WellPoint agreed to acquire Amerigroup for $5 billion in July, just a little over a week after the Supreme Court's decision to uphold the Affordable Care Act. Before that, Cigna paid $3.8 billion for HealthSpring in another bet on the expansion of Medicaid and Medicare.
Companies like Aetna, WellPoint and Cigna have all gravitated to rivals with a foothold in government-sponsored programs because the prevailing view is that margins for private customers are going to steadily erode. According to Aetna on Monday, the acquisition of Coventry will "substantially increase Aetna's Medicaid footprint, creating more opportunity to participate in the expansion of Medicaid and to pursue high acuity positions as they move into managed care." Aetna's revenue from the government will jump to 30 percent from 23 percent.
In fairness, it is possible to argue that the election will be immaterial to the future of the Affordable Care Act. Even if Mr. Romney wins the presidency, depending on which parties are in the House and Senate, the act may be impossible to roll back.
"Some will argue that with the election just over two months away, the company could have been more prudent in its timing," the Barclays analyst wrote. "Our take is that the election, reform and other potential legislative issues will have little impact on this transaction."
David Einhorn of Greenlight Capital recently made the contrarian case that companies like Cigna would actually do better if the law were to be repealed, ostensibly because of the margin compression that is likely as a result of the new law.
"While the stocks are already cheap, there is the additional unpriced upside in the possibility that the election changes the political landscape, resulting in a possible modification or repeal of Obamacare," he wrote in a letter to investors last month.
Still Mr. Einhorn, through smarts or luck, made a big investment in Coventry in the last quarter. With the sale to Aetna, irrespective of his investment thesis, Mr. Einhorn's firm just made about $72 million.
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July 2, 2012 Monday
John Roberts Conspiracy Theories
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 221 words
HIGHLIGHT: Why did the chief justice uphold the Affordable Care Act?
Why did the chief justice uphold the Affordable Care Act?
Love, according to Donald Trump: "He voted for it and he did it, in my opinion, politically and he wanted to be loved by the establishment."
Fear, according to Michael Walsh of The National Review: "Even if Roberts did make his 'switch in time' pusillanimously, to avoid another Obama tongue-lashing and the ill will of the major editorial pages so what?" [Ed. Note: By tongue-lashing he means the president's criticism of the Supreme Court at the 2010 State of the Union.]
Medication, according to Michael Savage, the right-wing radio host: "It's well known that Roberts, unfortunately for him, has suffered from epileptic seizures. Therefore he has been on medication. Therefore neurologists will tell you that medication used for seizure disorders, such as epilepsy, can introduce mental slowing, forgetfulness and other cognitive problems. And if you look at Roberts' writings you can see the cognitive dissociation in what he is saying."
Coercion, according to the To Be Right blog: "Someone got to Roberts. I bet they got to him and told him he has to vote this way or members of his family - kids, wife, parents, whoever - were going to be killed."
Romney's Call to Arms
Roberts Hits the Reset Button
Lies About Health Care
Opinion Report: Health Care
Health Care Confusion
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September 25, 2014 Thursday
Late Edition - Final
Health Act Reduces Costs for Hospitals, Report Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 670 words
WASHINGTON -- The Obama administration increased the pressure on states to expand Medicaid on Wednesday, citing new evidence that hospitals reap financial benefits and gain more paying customers when states broaden eligibility.
In states that have expanded Medicaid, the White House said, hospitals are seeing substantial reductions in ''uncompensated care'' as more patients have Medicaid coverage and fewer are uninsured.
Sylvia Mathews Burwell, the secretary of health and human services, and Jason Furman, the chairman of President Obama's Council of Economic Advisers, said the data should persuade more states to expand Medicaid.
''Because of the Affordable Care Act,'' Ms. Burwell said, ''we project that hospitals will save $5.7 billion in uncompensated care costs this year. Hospitals in states that have expanded Medicaid are projected to save up to $4.2 billion of the total amount.''
Twenty-seven states have expanded Medicaid. Many of the others, which have balked until now, are likely to reconsider the issue when state legislatures convene next year.
White House officials said they wanted to work with Republican governors on Medicaid, as they did with Gov. Tom Corbett of Pennsylvania, a Republican. They reached an agreement with Mr. Corbett last month on a plan to expand Medicaid by using federal funds to buy private health insurance for about 500,000 low-income people.
The administration did not single out other states for special attention, but Florida, Georgia, North Carolina and Texas -- all with Republican governors -- are obvious candidates. Health policy experts estimate that 3.5 million people could gain coverage if those states expanded their Medicaid programs.
Uncompensated care represents the combined total of unpaid hospital bills and charity care provided to low-income patients.
Financial reports from investor-owned hospitals and surveys by several state hospital associations show that Medicaid expansion has reduced the number of patients who cannot pay their bills, Ms. Burwell said in issuing a report on trends in uncompensated care.
The study was part of a White House campaign to improve public perceptions of the Affordable Care Act before the midterm elections on Nov. 4 and the start of the next annual open enrollment period for people to buy health insurance, beginning on Nov. 15.
In the first enrollment period, which ended five months ago, the White House orchestrated an extensive national effort to enroll seven million people in private health plans through the federal and state insurance exchanges. The White House said it had signed up eight million people, of whom 7.3 million have paid their premiums and still have coverage.
Ms. Burwell declined Wednesday to set a numerical goal for the new open enrollment season. She said she was considering whether to do so.
The Congressional Budget Office has estimated that enrollment through the exchanges will climb to a total of 13 million next year and 24 million in 2016.
Charles N. Kahn III, the president of the Federation of American Hospitals, which represents investor-owned companies, said, ''The increased payments for previously uncompensated care are a plus for hospitals.'' But he added: ''You have to remember the context. We are living with heavy cuts in Medicare, which were put in place by the Affordable Care Act.''
Federal officials analyzed financial reports from hospital operators like HCA Holdings and Tenet Healthcare, as well as data collected from two dozen states by the Colorado Hospital Association. In states that expanded Medicaid, they said, hospitals reported increases in Medicaid admissions ranging from 17 percent to 32 percent, with no evidence of significant increases in other states.
Nine states led by Republican governors have decided to expand Medicaid. But Gov. Bobby Jindal of Louisiana, the vice chairman of the Republican Governors Association, has opposed expansion, saying it would move tens of thousands of people in his state from private insurance onto a government program.
URL: http://www.nytimes.com/2014/09/25/us/health-act-cuts-spending-at-hospitals-report-finds.html
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November 20, 2016 Sunday 00:00 EST
Many Insured Children Lack Essential Health Care, Study Finds
BYLINE: MARC SANTORA
SECTION: NYREGION
LENGTH: 1335 words
HIGHLIGHT: A new report criticizes an often confusing and expensive system that creates barriers to receiving care, even as a record number of young people now have insurance.
Correction Appended
Margo Solomon has health insurance for herself and her four children.
But actually getting treatment is another matter.
Ms. Solomon, a 35-year-old mother from the Bronx, says she has struggled to find a doctor who accepts her insurance. And with three of her children coping with asthma, and one with more complicated medical problems, locating a specialist is even more challenging. And once in the door, she cannot afford the costs, including for deductibles and medications.
"I feel like I am all alone out here," Ms. Solomon said.
She is not alone.
A new study to be released on Monday by the Children's Health Fund, a nonprofit based in New York City that expands access to health care for disadvantaged children, found that one in four children in the United States did not have access to essential health care, though a record number of young people now have health insurance.
The report found that 20.3 million people in the nation under the age of 18 lack "access to care that meets modern pediatric standards."
Guidelines issued by theAmerican Academy of Pediatrics say that all children should get health maintenance visits for immunizations and other preventive services; management of acute and chronic medical conditions; access to mental health support and dental care; and have round-the-clock availability of emergency services and timely access to subspecialists.
While Medicaid and many private insurance plans recommend or require that all of those services be provided, under the umbrella of what is known as the medical home, the study found that millions of insured children are not receiving many of the benefits.
There are many children with insurance who cannot get primary care and those who do can often have problems getting specialty care.
As President-elect Donald J. Trump, a Republican, vows to repeal some, if not all, of the Affordable Care Act, which extended health care coverage to an additional 20 million people, the report's authors worry that even more children could have trouble receiving the care they need.
"The fact that more than 20 million children in the U.S. experience insurance and noninsurance barriers to getting comprehensive and timely health care is a challenge that needs to get the highest-priority attention from the new administration," said the report's lead author, Dr. Irwin Redlener, president of the nonprofit Children's Health Fund and a professor of pediatrics and health policy and management at Columbia University.
Over the past two decades, the number of children without health insurance has steadily decreased to 3.3 million last year from around 10 million in 1997, according to an analysis of federal data and the federal government's 2015 National Health Interview Survey.
The effort to extend coverage began 50 years ago with the creation of Medicaid, which provides health insurance for the poor. It continued more recently with the Children's Health Insurance Program, which offers low-cost coverage to those who make too much money to qualify for Medicaid and, under the Obama administration, with the Affordable Care Act, offering subsidized coverage and state exchanges.
The study relied on census data and reports by federal agencies like the Centers for Disease Control and Prevention, prominent medical journals, as well as information extrapolated from the fund's clinics and from its national network of programs that provide health care to underserved children across the country.
The findings reveal a system in which getting quality care is often confusing and expensive, with even those who benefit from government programs often becoming deeply frustrated.
For the insured, affordability is still an issue. The report noted that employer-based health insurance premiums for family coverage increased by 73 percent from 2003 to 2013. Employees' contributions to the cost of the premiums climbed by 93 percent over that same period, though the rate of increase slowed after the passage of the Affordable Care Act in 2010. The average deductible for an individual with health insurance was 5 percent of median income in 2013, up from 2 percent in 2003, the report said.
The study also cited a survey that found that 59 percent of pediatricians said they had a hard time collecting patients' shares of deductibles and co-payments from families covered by private high-deductible health plans.
For those with Medicaid, like Ms. Solomon, difficulties in getting care have also grown.
Many clinics and health systems do not accept patients with Medicaid, the study said, because of the low reimbursement rates.
Ms. Solomon's experience is typical.
"When I was pregnant with my last child, I had such a hard time finding prenatal care," she said. She called 15 to 20 doctors before finding one who took her insurance. "I mean, we would call places and they would be like, 'We take it,' but it turned out they didn't," she said. "It was so hard."
Even something as simple as getting medicine recently for her son's strep throat was not simple. Because of a mix-up with her insurance card, Ms. Solomon had to cover a $20 co-payment for a prescription that should have been free, she said.
The report said experiences like hers were common, both with government programs and some private insurers.
"The impacts of these barriers are significant," the report said. "Parents faced with financial barriers might seek to save money by calling their doctor for advice, rather than seeing that doctor in person; rather than fill expensive prescriptions, a parent might rely on a limited supply of pharmaceutical samples. The medical debt incurred by such costs has been linked to reduced access to care, creating a vicious cycle."
Perhaps just as significant are the barriers caused by demographics.
Dr. Michael Kappy, a pediatric endocrinologist at Children's Hospital Colorado just outside Denver, has seen the problem firsthand.
Since 1996, he has traveled in Colorado, Montana and Wyoming to reach children in areas that do not have large medical centers or specialists.
"My focus has been strictly speaking to solving the geographic barrier," Dr. Kappy said.
The study estimates that around 14 million children live in areas with a shortage of health professionals. More than three million low-income residents in New York live in federally designated shortage areas where, among other criteria, there is less than one primary care doctor for every 3,000 people.
The Affordable Care Act sought to address that problem by expanding the National Health Service Corps, but 65 percent of rural areas still have shortages of health professionals.
Dr. Kappy said one encouraging trend was the use of telemedicine, allowing for patients to be evaluated over the internet, with a local physician assistant aiding with hands-on work. To expand and improve tele-health options, however, the programs need to be properly reimbursed, he said, adding that programs that fund the work of doctors doing outreach to isolated communities were critical.
Dr. Redlener, the study's chief author, warned that repealing the Affordable Care Act without an adequate replacement could result in more than three million children losing their insurance.
"So far," Dr. Redlener said, "none of the proposed replacements will do anything to mitigate what children would potentially lose if the A.C.A. is actually repealed."
Correction: November 24, 2016, Thursday
This article has been revised to reflect the following correction: A picture caption with an article on Monday about a Children's Health Fund study misspelled the surname of a doctor at a mobile clinic. He is Dr. Scott Ikeda, not Ikea.
PHOTO: Dr. Scott Ikea with Sophie Miller's 9-month-old daughter, Sayeeda Ross, inside the Children's Health Fund's mobile clinic. (PHOTOGRAPH BY HIROKO MASUIKE/THE NEW YORK TIMES)
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August 7, 2013 Wednesday
In the Affordable Care Act, Some Children Left Behind
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1242 words
HIGHLIGHT: Because of rules decided recently by the I.R.S., some workers could find family coverage all but impossible to obtain. Their best hope might be to ask their employers NOT to offer coverage.
When supporters talk about the Affordable Care Act, they often take pains to stress the law's light touch on small businesses. Those with fewer than 50 employees do not have to do anything under the law that they are not already doing, and the law provides temporary tax credits to the smallest companies for offering health coverage. That said, in at least one situation small companies may be forced to confront a surprising dilemma.
Let's imagine a small company with tight margins - a retailer, say - that employs 15 full-time people. Now suppose that this retailer offers health insurance to those employees and their families, but while the company pays most of the premium for each employee's individual insurance, the financial burden for family coverage is left entirely to the employees, a common practice.
In this case, the company's decision to offer family coverage may be little more than a gesture, given that the employees have to foot the bill and the coverage is likely to be prohibitively expensive for many of them. But decisions made recently by the Internal Revenue Service, which is writing many of the regulations to carry out the law, mean this gesture could make it extremely difficult for even middle-income employees to buy insurance for their families. The obvious but perverse result would be that these employees might well beg their employers NOT to offer them health insurance.
Here is how it works. Under the new law, employees look to their employers to provide health insurance coverage that is affordable and that meets certain standards for quality of coverage. Beginning in 2014, if the company does not offer individual insurance that meets the basic tests of affordability and quality, its employees can buy health policies for themselves on the new state exchanges, or marketplaces, where they are likely to receive tax credits to offset the cost of the premiums or other subsidies.
But here's the catch, and it's a big one. In the rules it has written, the I.R.S. treats the family members of these employees differently. If the company offers family members health insurance, they immediately become ineligible for the tax credits and subsidies - regardless of whether the insurance the company offers is affordable.
As a result, many workers, like those of our retailer, could find family coverage impossible to obtain. According to the Kaiser Family Foundation, among businesses with fewer than 25 employees, 36 percent require employees to pay at least half of the premiums for family coverage. And family coverage is expensive: the average cost in 2012 was $15,745, nearly a third of the median household income in 2009, the most recent year for which Census Bureau data is available. Kaiser has estimated that 3.9 million dependents of employees will be caught in this bind, shut out from affordable insurance from either the employer or the subsidized exchanges. Recognizing the issue, the I.R.S. has decided to exempt those dependents from the individual mandate penalty.
Companies with fewer than 50 employees, like our imagined retailer, have a simple but counterintuitive solution. These businesses have no obligation to provide any health insurance at all, so the retailer could simply drop family coverage if it is too expensive while continuing to offer insurance to individual workers. The families could then buy insurance on the market with government assistance.
"We're going to be in a very strange situation where employees are going to be asking their employer to not offer insurance," said Alan Cohen, chief strategy officer for Liazon, which operates a private benefits exchange for employers.
For businesses above that 50-employee threshold - which the law calls "large employers" - the situation is more complicated. These businesses are obligated by the law's employer mandate to provide both individual and dependent coverage to full-time employees or else pay a penalty, starting in 2015. (In an effort to ease the transition, the I.R.S. has announced it will waive mandate penalties in 2014.) That means that in 2015, if a company drops coverage for dependents, it might as well drop coverage for employees, too, because it will probably have to pay the penalty anyway.
The I.R.S. has limited the definition of dependent here to a child under 26 years old - spouses are not considered dependents for the purposes of the mandate, so employers have no obligation to offer them coverage. It is unclear how businesses might respond to this in 2015. But those that cannot afford to make family coverage affordable for their employees could begin offering policies that cover just the employee and children, and exclude spouses, who would then be able to use the subsidies for individual policies.
For other businesses, it will be cheaper to pay the penalty than to offer the insurance. Or they could choose to cut their employees' hours down from full time, so the company no longer has to offer them coverage. "You could have people saying things like, 'I'll still do all my work but just make me part time,'" Mr. Cohen said. But in either case, the action would be taken not to save the company money but to protect its employees. In those circumstances, he said, "the best thing for them is to drop health insurance."
However, if a company chooses not to drop health insurance, those employees will be stuck. Though the employer mandate also penalizes companies with more than 50 employees if the insurance offered individual workers is unaffordable, the law places no limits on the cost of the coverage made available to dependents.
Ron Pollack, the executive director of Families USA, which lobbied for the law, said employers ought to forestall the circumstance where workers volunteer to give up company health coverage by lobbying to change the rule - or offering more generous benefits. "The question is, how will employers react when they realize that a worker has declined coverage because the worker wants to cover the entire family," he said, "and will they have some sensitivity to that if they don't already?"
Updated, 10:04 a.m. | A senior administration official with knowledge of tax policy, who asked to speak anonymously in order to discuss the administration's internal deliberations, said the I.R.S. was unlikely to revisit the regulation. The I.R.S. ruling "interpreted the statute in the way that Treasury and I.R.S. felt was correct, based on the language of the statute," the official said. "This was reading the law in the most defensible way."
That said, this official added, many of the children affected could get affordable coverage through Medicaid or the Children's Health Insurance Program. And, the official said, changes brought about by the health law will make it cheaper for companies to offer family coverage without passing so much of the cost on to employees. "Our expectation is that with the reduction in cost overall due to the Affordable Care Act and, in the case of small business, the tax credits, there will be a lot of employers who will provide more family coverage under the Affordable Care Act than they have before," the official said.
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
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Could Employers Use Immigrants to Avoid the Health Mandate?
Bakery Owner Talks About Coping With Health Insurance Changes
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February 8, 2015 Sunday
Late Edition - Final
Insured, but Not Covered
BYLINE: By ELISABETH ROSENTHAL.
Elisabeth Rosenthal is a New York Times correspondent who is writing a book about the health care system.
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WHEN Karen Pineman of Manhattan received notice that her longtime health insurance policy didn't comply with the Affordable Care Act's requirements, she gamely set about shopping for a new policy through the public marketplace. After all, she'd supported President Obama and the act as a matter of principle.
Ms. Pineman, who is self-employed, accepted that she'd have to pay higher premiums for a plan with a narrower provider network and no out-of-network coverage. She accepted that she'd have to pay out of pocket to see her primary care physician, who didn't participate. She even accepted having co-pays of nearly $1,800 to have a cast put on her ankle in an emergency room after she broke it while playing tennis.
But her frustration bubbled over when she tried to arrange a follow-up visit with an orthopedist in her Empire Blue Cross/Blue Shield network: The nearest doctor available who treated ankle problems was in Stamford, Conn. When she called to protest, her insurer said that Stamford was 14 miles from her home and 15 was considered a reasonable travel distance. ''It was ridiculous -- didn't they notice it was in another state?'' said Ms. Pineman, 46, who was on crutches.
She instead paid $350 to see a nearby orthopedist and bought a boot on Amazon as he suggested. She has since forked over hundreds of dollars more for a physical therapist that insurance didn't cover, even though that provider was in-network.
The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.
The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources -- such as separate deductibles for network and non-network care, or payments for drugs on an insurer's ever-changing list of drugs that require high co-pays or are not covered at all.
For some, like Ms. Pineman, narrow networks can necessitate footing bills privately. For others, the constant changes in policy guidelines -- annual shifts in what's covered and what's not, monthly shifts in which doctors are in and out of network -- can produce surprise bills for services they assumed would be covered. For still others, the new fees are so confusing and unsupportable that they just avoid seeing doctors.
It is true that the Affordable Care Act has erased some of the more egregious practices of the American health insurance system that left patients bankrupt or losing homes to pay bills. Insurers can no longer deny coverage to those with pre-existing conditions, for example. And the new policies cap out-of-pocket spending so long as the patient receives care within the plan. Most important, the act has offered health insurance to an estimated 10 million Americans who did not have any, often by expanding Medicaid or providing subsidies.
But by endorsing and expanding the complex new policies promoted by the health care industry, the law may in some ways be undermining its signature promise: health care that is accessible and affordable for all.
''I'm always curious when I read this 'good news' that health costs are moderating, because my health care costs go up significantly each year, and I think that's a common experience,'' said Mark Rukavina, president of Community Health Advisors in Massachusetts.
While much of the focus in the past has been on keeping premiums manageable, ''premiums now tell only a part of the story,'' Mr. Rukavina said, adding: ''A big part of the way they've kept premiums down is to shift costs to patients in the form of co-pays and deductibles and other types of out-of-pocket expenses. And that can leave patients very vulnerable.''
Such policies desperately need improvement, patients and professionals like Mr. Rukavina say. But with the Republicans attacking the Affordable Care Act at all turns, even political supporters seem reluctant to acknowledge that it has some flaws. The narrative has been cast in black or white: It's working, or it's a failure. The reality, of course, is gray.
AT this point, we don't have a good definition of ''affordable'' -- or how to measure it fully and fairly. Many studies show that national health costs, while still rising, are not growing as fast as they once were. But what does that mean for individual patients? So far the research has yielded mixed results.
A study by the Commonwealth Fund this month found that the rise in health insurance premiums in employer-based plans had slowed in 31 states since the passage of the Affordable Care Act (good news, right?). But premiums were still rising faster than median incomes (hmm). More important, perhaps, the researchers found that patients were paying more in health care expenses than ever before, during a time of stagnant wages (not so great). In fact, nearly 10 percent of median household income now goes to pay premiums and deductibles, the study found. And that does not include other kinds of health payments that patients now encounter, such as co-pays and uncovered drugs or services.
A recent New York Times/CBS poll found that 46 percent of Americans said they had trouble affording health care, up 10 percentage points in just one year. Some of the cost problems may ease as patients -- now known as health care consumers -- learn what to expect and how to choose and navigate their plans.
But other problems may be related to the process by which the plans are created. Under the Affordable Care Act each state was asked to select a benchmark plan as its standard. It had to cover certain ''essential health benefits'' like maternity care and prescription drugs; it had to have a defined actuarial value depending on the level of plan. Silver plans, for example, had to cover 70 percent of charges, leaving consumers with 30 percent. But within those parameters, competing insurers had leeway to set premiums, co-payments and deductibles, and to create networks by negotiating with doctors and hospitals. Naturally, they created policies that met the core criteria while minimizing their financial risk.
Suddenly there were hundreds of new insurance products that had never been tested in real time. Their shortcomings are now playing out in various ways.
Alison Chavez, 36, who is self-employed, signed up for a marketplace plan in October 2013 that she hoped would be an improvement on her previous plan. She had recently been given a diagnosis of breast cancer and was just beginning therapy, so she was careful to choose a policy on the Covered California marketplace that included her physicians.
But in March, while in the middle of treatment, she was notified that several of her doctors and the hospital were leaving the plan's network. She was forced to postpone a surgery as she scrambled to buy a new commercial policy that included her doctors. ''I've been through hell and back, but I came out alive and kicking (just broke),'' she wrote in an email.
Dr. Alexis Gersten, a dentist in East Quogue, N.Y., switched her family and 11 employees to a new Blue Cross/Blue Shield plan for 2014, after a previous small-business group plan was canceled. She bought the plan through a broker, and says she was unaware that it was an Affordable Care Act plan. When her son needed an ear, nose and throat specialist, the nearest was in Albany, five hours away. Though her cardiologist was on the network list, he said he did not take the plan. She ended up driving an hour to see a new one. A dispute with the insurer about how to count deductibles left her with a $457 pediatrician's bill. This year she has chosen a new policy.
''People may have a checklist when they buy insurance: First, premiums, then the deductible -- and those are pretty easy to understand because they're set dollar amounts,'' said Lynn Quincy, associate director of health reform policy at Consumers Union. But new policies demand different and more difficult kinds of calculations, she said: ''The terms are unfamiliar, and figuring out networks is especially murky.''
Compounding the problem is the lack of basic information to shop effectively. When Andrea Greenberg, a New York lawyer, called the help line of Health Republic to clarify the difference between two plans, she found herself speaking to someone reading off a script in the Philippines. ''I was really outraged,'' she said. ''This is an important decision with potentially dire consequences. It's not like you're choosing a sweater.''
Likewise, it took many phone calls for Aviva Starkman Williams, a California computer engineer with insurance through her employer, to determine whether the pediatrician doing her son's 2-year-old checkup was in-network for 2015. Only three of the pediatricians in her doctor's six-person group were listed in her plan's online directory, and since her deductible had tripled from the previous year's, she wanted to limit her out-of-pocket payments.
The practice's office manager couldn't tell her for sure. The insurer's representative said he didn't know because doctors came in and out of network all the time, likening the situation to players' switching teams in the National Basketball Association. ''If you don't have updated information, who does?'' she asked. ''Isn't it your job to know?''
Ms. Quincy said regulators needed to do a much better job setting requirements and policing plan practices and offerings, particularly provider networks. Few states have clear standards and many rely on consumer complaints to ferret out problems.
Last month, the California insurance commissioner, Dave Jones, announced new emergency regulations concerning networks, noting: ''Health insurers' medical provider directories have been inaccurate, misleading consumers into signing up with a health insurer for access to a doctor, specialist or hospital, only to learn that these medical providers are not actually a part of the health insurer's network.''
But for now, patients are most often left to fend for themselves. When Amy Moses, a tech entrepreneur in New York City, went online to select a plan, she paid a relatively pricey $650 per month for a United Healthcare plan to make sure her network included a longtime physician. One month into the year, the doctor's practice was bought by a hospital, which then dropped the plan, so her doctor did as well. (A year later the doctor was still listed in the network directory.)
She discovered the change only when she contacted the physician for a referral for an urgent outpatient procedure costing thousands of dollars that had been recommended by an in-network surgeon. (Both the referring doctor and the surgeon had to be in-network for coverage.) ''I literally had three days to find a new in-network internist and score an appointment to get a referral, or cancel my procedure,'' she said. ''I was stuck in insurance purgatory.''
For a continuing conversation about health care costs and pricing in the United States, please join our Facebook group, Paying Till It Hurts.
URL: http://www.nytimes.com/2015/02/08/sunday-review/insured-but-not-covered.html
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September 5, 2012 Wednesday
Medicare Part D Premiums Holding Steady
BYLINE: PAULA SPAN
SECTION: HEALTH
LENGTH: 268 words
HIGHLIGHT: The average 2013 premiums for Medicare Part D coverage will remain basically level for the fourth year in a row.
A morsel of good news about Medicare drug coverage for the coming year: Selecting a Part D plan might drive you crazy, as Jane Gross, the founding New Old Age blogger, wrote earlier this summer, but at least the average 2013 premiums will remain basically level for the fourth year in a row.
As it has since 2010, the average monthly premium is projected to hover around $30, the federal Department of Health and Human Services has announced. Last year, the actual amount came in a few cents lower, at $29.67. And the dread doughnut hole, which this year suspends coverage once spending hits $2,930, will kick in a few dollars later, at $2,970.
More important is that the discounts applied to drug costs once a beneficiary hits this coverage gap will continue to rise, courtesy of the Affordable Care Act. This year, beneficiaries in the hole received a 50 percent discount on brand-name drugs and 14 percent for generics. Next year, those discounts climb a bit, to 52.5 percent and 21 percent. By 2020, the hole is scheduled to close completely.
The number of people taking advantage of these discounts has grown, too. Through July this year, 1.41 million beneficiaries had received savings averaging $629, compared with 1.28 million people at that point in 2011.
Unhappily, some people are likely to pay more for drugs, either because their Part D premiums rise more than this national average or because price increases for their prescriptions outpace the rising doughnut-hole discounts. That's why this constitutes merely a morsel of good news, but we'll take it.
The annual enrollment period begins Oct. 15.
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October 23, 2015 Friday
Late Edition - Final
Investigation Finds Errors in Coverage and Payments Under Affordable Care Act
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 986 words
WASHINGTON -- Federal investigators from the Government Accountability Office said Thursday that they had discovered many errors in eligibility decisions under the Affordable Care Act that had led the government to pay for duplicate coverage for some people and an excessive share of costs for others.
The investigators said some people were receiving subsidies for private insurance at the same time they were enrolled in Medicaid.
In other cases, the investigators said, the government is probably overpaying because it cannot always distinguish between newly eligible beneficiaries under the Affordable Care Act and those eligible under the old rules. The federal government is paying 100 percent of the cost of Medicaid for newly eligible people, but for others, it should pay a much smaller share, averaging 57 percent of the costs.
The discrepancy is potentially significant, the investigators said, because the federal government expects to spend more than $400 billion on newly eligible Medicaid beneficiaries from 2014 to 2023.
The accountability office, a nonpartisan investigative arm of Congress, described its findings in three reports to the House Energy and Commerce Committee and the Senate Finance Committee. The reports came 10 days before millions of people will start applying for subsidized health insurance through online federal and state marketplaces, also known as exchanges.
The Obama administration, commenting on the reports, said it was intensifying its efforts to ''prevent duplicate coverage'' under Medicaid and government-subsidized private insurance policies sold through the marketplaces. In addition, the administration said it had provided ''significant training and guidance'' to make sure states correctly identified new Medicaid beneficiaries for whom the federal government should pay the entire cost.
In testimony prepared for a House hearing on Friday, Carolyn L. Yocom and Seto J. Bagdoyan of the Government Accountability Office said the Obama administration needed to adopt much stronger safeguards to ensure the integrity of programs providing coverage to millions of Americans.
''The Centers for Medicare and Medicaid Services cannot identify erroneous expenditures due to incorrect eligibility determinations,'' said Ms. Yocom, a director of health care studies at the accountability office. ''The federal government could be paying twice -- subsidizing exchange coverage and reimbursing states for Medicaid spending -- for individuals enrolled in both types of coverage.''
Moreover, the auditors said, the Centers for Medicare and Medicaid Services, which runs the federal marketplace, ''does not have procedures to automatically terminate subsidized exchange coverage when individuals are determined eligible for Medicaid.''
The administration said Sept. 28 that it had started a data-matching program to help ensure that Medicaid beneficiaries would not receive subsidies through the marketplace. But the accountability office said this was not enough to minimize the potential for duplicate coverage.
In a separate study, undercover investigators from the accountability office created 18 fictitious identities and filed applications in their names.
Federal and state officials approved subsidies or Medicaid coverage for 17 of the applicants, even though they used nonexistent Social Security numbers, invalid immigration document numbers, fictitious birth certificates and other counterfeit documents.
''Our undercover testing for the 2015 coverage year found that the health care marketplace eligibility determination and enrollment process remains vulnerable to fraud,'' said Mr. Bagdoyan, the director of forensic audits at the accountability office.
In one case, Mr. Bagdoyan said, a fictitious applicant received subsidized insurance coverage from the federal marketplace and from two state marketplaces at the same time.
Federal and state officials ''told us there is no current process to identify individuals with multiple enrollments through different marketplaces,'' Mr. Bagdoyan said.
Federal officials told auditors that they would ''look at the risk associated with multiple coverage,'' according to one of the accountability office's reports.
''The undercover results, while illustrative, cannot be generalized to the full population of enrollees'' in the insurance exchanges, Mr. Bagdoyan said. But the findings are potentially embarrassing for the administration, especially because Mr. Bagdoyan and his team found similar weaknesses when they conducted undercover tests in 2013-14.
Meaghan Smith, a spokeswoman for the Department of Health and Human Services, said the department's online verification systems had thwarted the investigators' initial attempts to enroll, and she noted that consumers must attest to information they provide under penalty of perjury.
Federal and state officials often ask consumers for documents with their applications. But ''if the documentation submitted does not appear to have any obvious alterations, it would not be questioned for authenticity,'' Mr. Bagdoyan said.
The accountability office found that states had made incorrect decisions about Medicaid eligibility, leading to the ''enrollment of individuals with incomes exceeding Medicaid standards.'' In addition, it said, the federal government continued to pay subsidies for private insurance for some people after they obtained Medicaid, and states often have difficulty determining whether Medicaid beneficiaries have other sources of coverage.
The investigators also found a significant risk that people moving to insurance on the federal exchange from Medicaid would have gaps in coverage because their records were not transferred promptly from state Medicaid agencies to the exchange.
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URL: http://www.nytimes.com/2015/10/23/us/politics/affordable-care-act-health-care-law-fraud.html
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February 18, 2015 Wednesday
Late Edition - Final
More Than 11 Million Have Chosen or Renewed Health Plans, Obama Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 435 words
WASHINGTON -- President Obama said Tuesday that 11.4 million people had selected private health insurance plans or renewed their coverage under the Affordable Care Act in the enrollment period that ended Sunday.
''It gives you some sense of how hungry people were out there for affordable, accessible health insurance,'' Mr. Obama said in a video released by the White House.
Administration officials said the numbers would grow in the next week as insurance marketplaces, or exchanges, signed up people who had tried to enroll but encountered technical problems on HealthCare.gov or state insurance websites.
The White House celebrated the latest numbers as evidence of the success of the health law, which was adopted in 2010 without any Republican votes.
''The Affordable Care Act is working,'' Mr. Obama said. ''It's working a little bit better than we anticipated -- certainly, I think, working a lot better than many of the critics talked about early on.''
More than a million people selected health plans in the last nine days of the latest open enrollment period.
''On the final day,'' said Sylvia Mathews Burwell, the secretary of health and human services, ''we had more consumers sign up than we've every had, last year or this year.''
Many people cited the threat of tax penalties as a reason for obtaining insurance.
Federal health officials emphasized that the latest numbers were preliminary. People are not formally enrolled until they pay the first month's premium. Some people who gain insurance and pay the initial premium lose the coverage because they do not pay their share of premiums in later months.
Ms. Burwell had set a relatively modest goal for 2015, saying she wanted to have 9.1 million people signed up and paying premiums at the end of the year. The Congressional Budget Office had projected enrollment of 12 million for 2015.
The administration has had difficulty establishing a firm count of people gaining insurance under the health law.
In April 2014, Mr. Obama announced that eight million people had signed up in the initial enrollment period that had ended March 31. By October, that number had declined to 7.1 million because some people failed to pay premiums or were found ineligible because of unresolved questions about their citizenship or immigration status.
The number shrank again in November, to 6.7 million, as congressional investigators discovered that the administration had overstated enrollment by including about 400,000 people with dental insurance.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2015/02/18/us/obama-cites-health-plan-tally-of-11-4-million.html
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February 18, 2015 Wednesday
Late Edition - Final
More Than 11 Million Have Chosen or Renewed Health Plans, Obama Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 435 words
WASHINGTON -- President Obama said Tuesday that 11.4 million people had selected private health insurance plans or renewed their coverage under the Affordable Care Act in the enrollment period that ended Sunday.
''It gives you some sense of how hungry people were out there for affordable, accessible health insurance,'' Mr. Obama said in a video released by the White House.
Administration officials said the numbers would grow in the next week as insurance marketplaces, or exchanges, signed up people who had tried to enroll but encountered technical problems on HealthCare.gov or state insurance websites.
The White House celebrated the latest numbers as evidence of the success of the health law, which was adopted in 2010 without any Republican votes.
''The Affordable Care Act is working,'' Mr. Obama said. ''It's working a little bit better than we anticipated -- certainly, I think, working a lot better than many of the critics talked about early on.''
More than a million people selected health plans in the last nine days of the latest open enrollment period.
''On the final day,'' said Sylvia Mathews Burwell, the secretary of health and human services, ''we had more consumers sign up than we've every had, last year or this year.''
Many people cited the threat of tax penalties as a reason for obtaining insurance.
Federal health officials emphasized that the latest numbers were preliminary. People are not formally enrolled until they pay the first month's premium. Some people who gain insurance and pay the initial premium lose the coverage because they do not pay their share of premiums in later months.
Ms. Burwell had set a relatively modest goal for 2015, saying she wanted to have 9.1 million people signed up and paying premiums at the end of the year. The Congressional Budget Office had projected enrollment of 12 million for 2015.
The administration has had difficulty establishing a firm count of people gaining insurance under the health law.
In April 2014, Mr. Obama announced that eight million people had signed up in the initial enrollment period that had ended March 31. By October, that number had declined to 7.1 million because some people failed to pay premiums or were found ineligible because of unresolved questions about their citizenship or immigration status.
The number shrank again in November, to 6.7 million, as congressional investigators discovered that the administration had overstated enrollment by including about 400,000 people with dental insurance.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2015/02/18/us/obama-cites-health-plan-tally-of-11-4-million.html
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The New York Times
April 5, 2017 Wednesday
Late Edition - Final
Latest Health Proposal Weakens Coverage for Pre-existing Conditions
BYLINE: By MARGOT SANGER-KATZ; Thomas Kaplan contributed reporting.
SECTION: Section A; Column 0; National Desk; PUBLIC HEALTH; Pg. 13
LENGTH: 1198 words
Throughout the debate to repeal and replace the Affordable Care Act, President Trump and Republican congressional leaders have insisted they would retain a crucial, popular part of the health law: the promise that people can buy insurance even if they've had illnesses in the past.
Their efforts foundered last month, when a House health bill had to be pulled from the floor after it failed to attract enough support. Late Monday night, word emerged that the White House and the group of conservative lawmakers known as the Freedom Caucus had discussed a proposal to revive the bill. But the proposed changes would effectively cast the Affordable Care Act's pre-existing conditions provision aside.
The terms, described by Representative Mark Meadows, Republican of North Carolina and the head of the Freedom Caucus, are something like this: States would have the option to jettison two major parts of the Affordable Care Act's insurance regulations. They could decide to opt out of provisions that require insurers to cover a standard, minimum package of benefits, known as the essential health benefits. And they could decide to do away with a rule that requires insurance companies to charge the same price to everyone who is the same age, a provision called community rating.
The proposal is not final, but Mr. Meadows told reporters after the meeting that his members would be interested in such a bill. To pass the House, any bill would need to find favor not just with the Freedom Caucus, but also with more moderate Republicans. It would also need to attract the support of nearly every Republican in the Senate to become law.
The ability to opt out of the benefit requirements could substantially reduce the value of insurance on the market. A patient with cancer might, for example, still be allowed to buy a plan, but it wouldn't do her much good if that plan was not required to cover chemotherapy drugs.
The second opt-out would make the insurance options for those with pre-existing conditions even more meaningless.
Technically, the deal would still prevent insurers from denying coverage to people with a history of illness. But without community rating, health plans would be free to charge those patients as much as they wanted. If both of the Obamacare provisions went away, the hypothetical cancer patient might be able to buy only a plan, without chemotherapy coverage, that costs many times more than a similar plan costs a healthy customer. Only cancer patients with extraordinary financial resources and little interest in the fine print would sign up.
There is a reason that many conservatives want to do away with these provisions. Because they help people with substantial health care needs buy relatively affordable coverage, they drive up the price of insurance for people who are healthy. An insurance market that did not include cancer care -- or even any cancer patients -- would be one where premiums for the remaining customers were much lower. The result might be a market that is much more affordable for people with a clean bill of health. But it would become largely inaccessible to anyone who really needs help paying for medical care.
We do not have to speculate to know what the world looks like without essential health benefits and community rating. It was how most state insurance markets worked before Obamacare. Back in 2009, most sick people who did not get insurance through work or a government program were excluded from coverage if they had a history of health problems like allergies or arthritis. Plans that did not cover pregnancy care or drug addiction treatment were widespread. (The data about individual market insurance premiums is a little spotty, but it appears that they were substantially lower in most states.)
One idea Republicans have about how to care for the sick was also in effect pre-Obamacare. Many states had ''high-risk pools,'' where people shut out of the traditional insurance markets could buy special plans with the help of state subsidies. The Freedom Caucus proposal is likely to include some money that states could use to set up such pools.
''The fundamental idea is that marginally sick people would pay with risk associated with their coverage,'' Mr. Meadows said Monday. ''Those that have, you know, premiums that would be driven up because of catastrophic illness or long-term illnesses, we've been dealing with that for a long time with high-risk pools.''
But insurance in the old high-risk pools tended to be expensive, and often came with long waiting periods or benefit limitations, even for the very sick.
The main difference between the policy environment in 2009 and today is that the federal government would now be offering tax credits to help healthy people buy what would probably be relatively skimpy plans. That would mean that more middle-income Americans would probably have health coverage than before the Affordable Care Act, since the combination of policies would tend to make insurance much more affordable for people who are young and healthy.
What states would choose to do with this set of options is hard to predict. Before Obamacare, few states required community rating of health plans. And few states required insurers to cover all of the benefits deemed essential under Obamacare, though most did require a few types of treatments to be covered. State governments would face a difficult choice: either take away the requirements, and leave sick patients without insurance options, or keep them and see people unable to afford coverage under the new subsidy system.
Under Obamacare, states can already waive many of the law's insurance rules if they can show that an alternative program would cover as many people with comprehensive coverage at a lower cost to the government. But that standard is difficult to meet. Mr. Meadows suggested that the waivers under discussion should be ''very easily granted'' to states.
The politics of health care in the United States have shifted since the Affordable Care Act was passed seven years ago. In recent months, the law has grown more popular, and the pre-existing conditions policy is among its best-known protections. That could create political pressure for states to keep the insurance rules, even if they are not required by law. But it is likely that at least some states might decide to eliminate them if they are made optional. Shifting norms about health insurance regulation may also affect the idea's reception in Congress.
Mr. Meadows said that the proposal presented to the Freedom Caucus would retain the pre-existing conditions policy. But that would be true in only the most literal sense. The mix of policies could allow insurance companies to charge sick people prices that few of them could pay. And it could allow them to exclude benefits that many healthy people need when they get sick. The result could be a world where people with pre-existing conditions would struggle to buy comprehensive health insurance -- just like before Obamacare.
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URL: http://www.nytimes.com/2017/04/04/upshot/freedom-caucus-health-care-pre-existing-conditions.html
LOAD-DATE: April 5, 2017
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GRAPHIC: PHOTO: Representative Mark Meadows, Republican of North Carolina, described his caucus's ideas on how to revive a failed health bill. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES)
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March 25, 2017 Saturday
The New York Times on the Web
In a Call to The Times, Trump Blames Democrats for the Failure of the Health Bill
BYLINE: By MAGGIE HABERMAN
SECTION: Section ; Column 0; Washington; Pg.
LENGTH: 584 words
WASHINGTON -- Just moments after the Republican plan to repeal and replace the Affordable Care Act was declared dead, President Trump sought to paint the defeat of his first legislative effort as an early-term blip.
The House speaker, Paul D. Ryan, was preparing to tell the public that the health care bill was being withdrawn -- a byproduct, Mr. Trump said, of Democratic partisanship. The president predicted that Democrats would return to him to make a deal in roughly a year.
''Look, we got no Democratic votes. We got none, zero,'' Mr. Trump said in a telephone interview he initiated with The New York Times.
''The good news is they now own health care. They now own Obamacare.''
Mr. Trump insisted that the Affordable Care Act would collapse in the next year, which would then force Democrats to come to the bargaining table for a new bill.
''The best thing that can happen is that we let the Democrats, that we let Obamacare continue, they'll have increases from 50 to 100 percent,'' he said. ''And when it explodes, they'll come to me to make a deal. And I'm open to that.''
Although enrollment in the Affordable Care Act declined slightly in the past year, there is no sign that it is collapsing. Its expansion of Medicaid continues to grow.
In a later phone interview with The Times, the Senate minority leader, Chuck Schumer, ridiculed Mr. Trump's remarks about Democrats being at fault.
''Whenever the president gets in trouble, he points fingers of blame,'' Mr. Schumer said. ''It's about time he stopped doing that and started to lead. The Republicans were totally committed to repeal from the get-go, never talked to us once. But now that they realize that repeal can't work, if they back off repeal, of course we'll work with them to make it even better.''
Mr. Trump said that ''when they come to make a deal,'' he would be open and receptive. He singled out the Tuesday Group moderates for praise, calling them ''terrific,'' an implicit jab at the House Freedom Caucus, which his aides had expressed frustration with during negotiations.
Even so, he tried to minimize the deep divisions within his own party that prevented Mr. Ryan from securing passage of the bill, and maintained that they were six to 12 votes away from getting it across the finish line.
As Mr. Trump spoke, his voice was flatly calm and slightly hoarse, his manner subdued. He talked on a speaker phone from his desk in the Oval Office, with a coterie of aides drifting by. At one point, he welcomed his daughter Ivanka back from a ski trip.
Mr. Trump said that in states he had visited in the last two weeks, Tennessee and Kentucky, the problems with President Barack Obama's signature legislation were evident. The president said he was now moving on to taxes and trade as priorities.
Mr. Trump described his first major legislative experience as not terribly different than what his previous negotiations as a real-estate developer had been like.
He emphatically did not fault Mr. Ryan.
''I don't blame him for a thing, I really don't,'' Mr. Trump said. He added: ''Even during the midst of negotiations I said the best thing that could happen was just to back off. I said, I'll do it now because I'm a team player.'' He said that Mr. Ryan did not apologize to him, adding: ''Look, he tried. He tried very hard.''
''I'm not disappointed,'' he insisted. ''If I were, I wouldn't be calling you.''
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URL: http://www.nytimes.com/2017/03/24/us/politics/donald-trump-health-care.html
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April 21, 2017 Friday
Late Edition - Final
Busy Congress Is First Hurdle For Health Bill
BYLINE: By MATT FLEGENHEIMER and REED ABELSON; Maggie Haberman contributed reporting from New York, Thomas Kaplan from Crossville, Tenn., and Margot Sanger-Katz from Washington.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1453 words
WASHINGTON -- White House officials, desperate to demonstrate progress on President Trump's promise to repeal the Affordable Care Act, are pushing to resurrect a Republican health care bill before his 100th day in office next week.
Some members of the president's team have grown consumed by that deadline, worrying that appraisals of the president's tenure will be brutal and hoping that a last push on health care might bring a measure of salvation.
But Congress usually cannot take on two big things at once. At the same moment Mr. Trump hits his 100th day on Saturday, April 29, Republican congressional leaders face a far more urgent deadline: Much of the federal government will run out of money.
Reaching agreement to keep the government open past midnight that Friday will be the first priority of Republican leaders when Congress returns Monday from a two-week recess.
''I believe that when we first go back, that's going to be the thing we'll address immediately and have to get done by Friday,'' said Representative Dan Donovan, Republican of New York.
The president himself has not laid down a hard deadline on the health care bill. ''We have a good chance of getting it soon,'' Mr. Trump said in a news conference Thursday. ''I'd like to say next week, but it will be -- I believe we will get it. And whether it's next week or shortly thereafter.''
Republican leaders and the White House have been searching for a health care agreement that could placate enough moderates and hard-line conservatives to win passage in the House.
The latest version of the proposal, published Thursday morning by Politico, would maintain popular benefits in President Barack Obama's signature domestic achievement, like guaranteed coverage for emergency services and maternity care. It would also preserve the health law's ban on insurers rejecting customers with pre-existing medical conditions.
But under this Affordable Care Act replacement, states could seek waivers from many of those mandates if they demonstrate that premiums would be lowered, the number of insured people would increase, or ''the public interest of the state'' would be advanced.
States could request an exemption from the rule intended to ensure that people with pre-existing conditions could not be charged prohibitive premiums -- but only if those states establish a high-risk insurance pool.
''The plan gets better and better and better, and it's gotten really, really good, and a lot of people are liking it a lot,'' Mr. Trump said. Asked if a health bill could pass as Congress tries to avert a government shutdown, the president said, ''I think we'll get both.''
The complications that remain in the bill are likely to be far too difficult to finesse at the same time the House and Senate press to pass a giant spending bill. Tussles over the spending deadline -- including possible debates over top administration priorities like a border wall and money for immigration enforcement officers -- are expected to consume the Capitol.
And Democrats -- whose votes will be needed to keep the government open -- will have their own demands, most importantly billions of dollars to lower out-of-pocket spending for low-income Americans purchasing health coverage on the Affordable Care Act's online marketplaces.
Senior Republicans appear unconvinced that a revised health care bill would ensure passage in the House. Mr. Donovan, an opponent of the original Republican health care bill, said the proposed amendment ''really doesn't address the concerns that I had.''
Representative Charlie Dent, Republican of Pennsylvania and a leader of the moderate House Tuesday Group, said it ''does nothing to change my views.'' He lamented any focus ''on an arbitrary 100-day deadline.''
The changes -- proposed by Representative Tom MacArthur, Republican of New Jersey and co-chairman of the Tuesday Group -- come as Republicans face anger from supporters over their failure to act on longstanding campaign pledges, as well as from defenders of the Affordable Care Act.
''We're in the midst of negotiating sort of finishing touches,'' Speaker Paul D. Ryan said this week in London while leading a congressional delegation.
He added: ''It's difficult to do. We're very close.''
But the legislation's future is unclear. For now, the proposal exists only in vague talking points. West Wing advisers to Mr. Trump are decidedly mixed in their views of how aggressively to raise expectations. The aide feeling perhaps the most pressure, according to people close to the discussions, is the chief of staff, Reince Priebus, who was blamed internally for the botched vote count around the first repeal effort and is closest to Mr. Ryan within Mr. Trump's circle.
The initial bill's failure has left lawmakers wary of artificial deadlines. And even a triumph in the House would not guarantee final passage, given the skepticism of several Republicans in the Senate.
''We want to make sure we replace it with something that will stand the test of time,'' Senator Bob Corker, Republican of Tennessee, said in a brief interview Thursday after speaking at a Rotary Club meeting in Crossville, Tenn. ''Now we're taking our time. We realize that this is real -- that it's going to affect people in a real way.''
The House bill's inability to garner enough support last month to be brought for a floor vote was an embarrassing setback for Mr. Trump, Mr. Ryan and the Republican conference.
This month, Vice President Mike Pence and other Trump administration officials sought a new agreement with the conservative House Freedom Caucus, whose opposition helped fell the first bill. The measure, which gained little traction, earned a nickname on Capitol Hill: Zombie Trumpcare.
Regardless of the bill's fate, lawmakers are approaching a critical moment on health care. Insurers and business groups are pressing hard for Republicans and Mr. Trump to maintain health insurance subsidies ahead of insurers' decisions in the coming weeks on whether to keep offerings on the Affordable Care Act's marketplaces and how much to charge for them.
Without those ''cost-sharing reductions,'' insurers warn that they will have to sharply raise the prices of their plans on the state marketplaces or leave the markets altogether.
About seven million people now qualify for the subsidies, which reduce the amount someone has to pay in deductibles and co-payments when they buy a plan. At stake is roughly $10 billion in payments expected to be made to the insurers next year. Some House Republicans oppose how the Obama administration funded them, and they won a court case potentially blocking the funding that is now on appeal. The next court date is May 22.
This week, insurance executives met with Medicare officials to plead their case. They left that meeting with Seema Verma, the new Medicare head, with no promises. Mr. Trump has publicly toyed with the idea of withholding the subsidies as a way to force Democrats to negotiate over the House proposal, and Ms. Verma told the insurers they should look to Congress to appropriate the money.
State insurance regulators with the National Association of Insurance Commissioners sent a letter to Congress on Wednesday, pleading, ''Your action is critical to the viability and stability of the individual health insurance markets in a significant number of states across the country.''
Insurers must begin the process of filing rates in the coming weeks, and many are looking at various scenarios, said David M. Dillon, a fellow at the Society of Actuaries, who has been working with state regulators and insurers about how to price plans in the marketplace. Insurers say their rates could rise as much as 30 percent, high enough to destabilize the markets.
Insurers remained largely silent on the proposed amendment, which seemed to revive a discussion of how to handle the sickest and most costly individuals by allowing states to set up high-risk pools. The insurers have previously indicated that they would be open to ideas that helped pay for people with very expensive conditions.
Separating off these individuals causes the cost of coverage for everyone else to go down, making it a potentially popular idea, said Stephen Zuckerman, a co-director of the Health Policy Center at the Urban Institute. But these pools have traditionally been poorly funded, leaving many people with potentially expensive pre-existing medical conditions without affordable coverage, if they can buy a plan at all.
''Why would these high-risk pools work better now than they have historically?'' Mr. Zuckerman asked.
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URL: https://www.nytimes.com/2017/04/20/us/politics/affordable-care-act-house-republicans-trump.html
LOAD-DATE: April 21, 2017
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GRAPHIC: PHOTO: Paul D. Ryan discussing the health bill on April 6. ''We're in the midst of negotiating sort of finishing touches,'' he said Thursday. (PHOTOGRAPH BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES) (A16)
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The New York Times
March 17, 2017 Friday
Late Edition - Final
The Debate Over How to Fix Health Care
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 805 words
To the Editor:
Re ''24 Million More Among Uninsured Under G.O.P. Plan'' (front page, March 14):
As a pediatrician working in a hospital, I care for the most sick and vulnerable children. In the past these children were often uninsured or underinsured, but we have made progress. Children's health insurance coverage has reached historic levels thanks to Medicaid, the Children's Health Insurance Program (CHIP) and the Affordable Care Act. The American Health Care Act could destroy that.
Children most at risk for poor health outcomes rely on Medicaid and CHIP -- those living in poverty, with disabilities or chronic health conditions, and in foster care, as well as very young infants. Half of all Medicaid/CHIP enrollees in the United States are children -- and yet we neglect to consider their welfare in the proposed health plan. And neglecting the welfare of children hurts our country and our economy.
Kids enrolled in Medicaid miss fewer school days, are more likely to attend and graduate from college, and grow up to be healthier adults who earn higher wages, pay more in taxes and have lower health care costs.
The American Health Care Act jeopardizes our nation's children. We must put kids first in order to ensure the health of our country.
ELIZABETH MEADE, SEATTLE
To the Editor:
A recent article in The New Yorker (''On Health Care, We'll Have What Congress Is Having'') explained why so many members of Congress hate, yes, hate the Affordable Care Act. They lost their access to the excellent Federal Employees Health Benefits Program, which covers federal employees, and were included instead in the less appealing Affordable Care Act, along with the unwashed millions.
They are still fuming. The lesson: One should never tamper with a politician's benefits, lest he exact awesome revenge.
My view: Let them have their benefits program back. Then maybe they will be kinder to the rest of the folks.
PEGGY TROUPIN, NEW YORK
To the Editor:
Re ''End Partisan Warfare on Health Care'' (Op-Ed, March 10):
It is more than merely disingenuous for Gov. John Kasich to claim that the Democrats ''chose to 'fix' health care unilaterally, without bipartisan support.''
President Obama bent over backward trying to bring the Republicans into the health care conversation. He jettisoned the public option in a New York minute to that purpose. The headline on this essay should have been used in 2010 to describe what the president wanted to happen.
Obstructionism is a dirty business, but for those who have engaged in it for eight years to now step up and call it out is the last way to accomplish anything bipartisan.
ROCHELLE L. ROTH, CONCORD, CALIF.
To the Editor:
John Kasich gets my vote today for his sane, solution-focused plea to end partisan warfare on health care. I have never understood how or why health care has become such a divisive partisan issues. We all age; we are all vulnerable to illnesses and disabilities. No family is immune to addiction or mental illness.
Do conservatives feel exempt? Do they blame poor sick people for their diseases? Do they need to deprive others to feel superior? We all benefit from a healthy population.
So let's heed Mr. Kasich, end the civil war over health care (and other safety nets) and begin to heal.
HARRIET ROSSETTO, LOS ANGELES
The writer is the founder of Beit T'shuvah, a faith-based addiction recovery community.
To the Editor:
Gov. John Kasich's calm call for a bipartisan reworking of the health care law seems at first blush to be the ''adult in the room'' wisdom we desperately need. But it is in reality only marginally better than the partisan screeching he is trying to reason past.
While Obamacare could certainly stand some strengthening, the rational way to proceed is to improve it, not ''repeal and replace'' it, as Mr. Kasich advocates. Ted Kennedy used to preach the virtues of passing even an imperfect bill on important issues and then fixing any flaws. That is the true ''adult'' wisdom we need today.
TOM GARDNER, NEW YORK
To the Editor:
The main reason that American health care costs have skyrocketed out of control is that medicine is no longer focused on healing the sick at affordable prices. Over the last 40 years, health care has grown into big business, and it is now on track to be the largest industry in the United States within the next few years.
The term ''nonprofit'' no longer applies to many health care providers. Many are public companies listed on the New York Stock Exchange and aim to maximize shareholder value and profits. They have contributed heavily to state and federal political campaigns, and they pay hundreds of millions of dollars to a vast army of Washington lobbyists.
Like it or not, the only solution is a nationwide single-payer health care system.
DANIEL ROBINOWITZ, DALLAS
URL: http://www.nytimes.com/2017/03/16/opinion/the-debate-over-how-to-fix-health-care.html
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The New York Times
January 6, 2017 Friday
Late Edition - Final
Democrats Appeal to Republicans: Alter Obama's Health Law, but Don't Gut It
BYLINE: By THOMAS KAPLAN and ROBERT PEAR; Emmarie Huetteman and Jennifer Steinhauer contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1118 words
WASHINGTON -- With Republican leaders pressing to dismantle the Affordable Care Act, possibly within weeks, moderate Senate Democrats reached out on Thursday to Republicans, appealing for them to slow down the repeal efforts and let lawmakers try to find acceptable, bipartisan changes to make the existing law work better.
Democrats also had new reason to hope for possible Republican defections after Speaker Paul D. Ryan of Wisconsin said that the repeal measure would cut off federal funds for Planned Parenthood. But for now, Republican leaders are holding firm. Senator Mitch McConnell of Kentucky, the majority leader, denounced the law, President Obama's signature domestic achievement, as ''a lesson to future generations about how not to legislate.''
Well before Republicans seized control of Washington, moderate Democrats and Republicans in the Senate had begun exploring ways to change the law, tempering its impacts on small business, seeking lower-cost insurance options and changing how quickly subsidies to help purchase insurance policies would phase out with rising incomes.
But those efforts were stymied by Republican leaders who had no interest in improving the health law and by Democratic leaders who saw reopening the law as a political Pandora's box. Now, Democrats have every interest in opening that box as repeal efforts barrel forward, and they would need to peel off only a few Senate Republicans to slow the fast-track repeal movement.
A possible pressure point is the effort to end funding for Planned Parenthood in the same measure that guts the health law. Already, that has raised questions about the support of two Republicans, Senators Susan Collins of Maine and Lisa Murkowski of Alaska.
''We ought to be talking about reform,'' Senator Tim Kaine of Virginia, who led the group of Democrats who reached out to Republican leaders, said on Thursday. ''And if Republicans want to call it 'replace' and we want to call it 'reform' or 'improvement' -- I don't care what we call it.''
''There's so much we can improve, but by pushing an immediate repeal through a partisan budget process, we won't have the opportunity to work together to build on that common ground,'' Mr. Kaine, who was the Democratic vice-presidential nominee, added.
Senate Republicans plan to muscle through a budget blueprint next week that clears the way for the repeal of major parts of the Affordable Care Act without the prospect of a Democratic filibuster. The House plans to take up the blueprint as soon as the Senate approves it.
House and Senate committees would then have until Jan. 27 to produce legislation that eviscerates a law that has extended health coverage to 20 million Americans and protected millions more from discriminatory insurance practices. But it has also been plagued by rising premiums and limited insurance company participation.
If Republicans succeed in gutting the law, they would need Democratic help to find a replacement, because the Republicans' narrow Senate majority would surely face a filibuster of a partisan health bill. ''We want their ideas,'' Mr. McConnell said. ''We want their input.''
But the effort to quickly undo a law that cost the Democrats so much effort and political capital could poison any chance of cooperation later this year.
Senator Chuck Schumer of New York, the Democratic leader, said on Thursday that Mr. McConnell and his colleagues have two options. One, he said, is for Republicans to devise a plan on their own to replace the health care law.
''Or don't repeal and come talk to us about how to make some improvements,'' Mr. Schumer said. ''We're willing to do that.''
For now, though, Republican leaders are in no mood to compromise. Senator John Cornyn of Texas, the No. 2 Senate Republican, dismissed the appeal from the group of Democrats as an ''act of desperation.''
''The fact is the wheels have been coming off of Obamacare for a long time now,'' he said, adding that he understood that the Democratic senators, ''as a political matter,'' feel that they need to defend the health care law.
The request for Republicans to slow down and work with them on changing the health care law came in a letter from 13 senators -- 12 Democrats and an independent, Angus King of Maine.
Moderate Democrats for years have been suggesting changes in the Affordable Care Act, based in part on complaints they were hearing from constituents.
In 2014, for example, Senators Heidi Heitkamp of North Dakota and Mark Warner of Virginia, both Democrats, proposed a lower-cost, high-deductible option -- a ''copper plan,'' to go along with bronze, silver, gold and platinum plans already available under the law. Both signed Mr. Kaine's letter.
As a possible model for bipartisan cooperation, senators pointed to a bill signed by Mr. Obama in October 2015 that protected small and midsize businesses from increases in health insurance premiums. Senators Jeanne Shaheen, Democrat of New Hampshire, and Tim Scott, Republican of South Carolina, led efforts to pass that bill. Ms. Shaheen also signed Mr. Kaine's letter.
White House officials said Mr. Obama did not particularly like that legislation but signed it after it won broad bipartisan support.
As Republicans moved ahead with their plans for repeal, the Planned Parenthood issue began picking up steam after Mr. Ryan said on Thursday that the health law repeal measure would cut off funds for the organization.
Such a provision could trouble moderate Senate Republicans whose votes are critical to passing repeal legislation.
''Yes, I'd have concerns,'' Ms. Murkowski said. ''I've long been a supporter of Planned Parenthood.'' But Ms. Murkowski said she did not know, without seeing a bill, if cutting the funding would be enough to cause her to vote against the health care repeal.
In 2015, Ms. Collins voted against a repeal bill because it would have cut off funds for Planned Parenthood. She expressed hope on Thursday that such a provision would not be in the repeal legislation this year.
In another possible trouble spot, members of the hard-right House Freedom Caucus met on Thursday with Senator Rand Paul, Republican of Kentucky, about the budget blueprint, weighing the possibility of opposing the measure because of its increases in federal spending and debt.
The group of conservatives has a history of opposing spending measures, often against the wishes of their party's leaders. Mr. Paul has said he will not support the budget blueprint because it would allow the government to add trillions of dollars to the federal debt in the coming decade.
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Senate Takes Major Step Toward Repealing Health Care Law
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HIGHLIGHT: By a 51-48 vote, the Senate approved a budget blueprint Thursday that would allow Republicans to gut the law without the threat of a filibuster.
WASHINGTON - Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to gut the health care law without the threat of a Democratic filibuster.
The vote was 51 to 48. During the roll call, Democrats staged a highly unusual protest on the Senate floor to express their dismay and anger at the prospect that millions of Americans could lose health insurance coverage.
One by one, Democrats rose to voice their objections. Senator Maria Cantwell of Washington said that Republicans were "stealing health care from Americans." Senator Ron Wyden of Oregon said he was voting no "because health care should not just be for the healthy and wealthy."
The presiding officer, Senator Cory Gardner, Republican of Colorado, repeatedly banged his gavel and said the Democrats were out of order because "debate is not allowed during a vote."
The final vote, which ended just before 1:30 a.m., followed a marathon session in which senators took back-to-back roll call votes on numerous amendments, an arduous exercise known as a vote-a-rama.
The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama's signature domestic policy achievement - a goal they believe can now be accomplished after Mr. Trump's election.
The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.
Republicans say the 2016 elections gave them a mandate to roll back the health care law. "The Obamacare bridge is collapsing, and we're sending in a rescue team," said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. "Then we'll build new bridges to better health care, and finally, when these new bridges are finished, we'll close the old bridge."
Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.
On Wednesday, Mr. Trump said he would offer his own plan to repeal and replace the law "essentially simultaneously." He said he would put forth the plan as soon as his nominee forsecretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed.
The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. More than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law's health exchanges.
The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.
Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date.
"We understand that everyone here understands the importance of doing it right," he said. He described the Jan. 27 date in the budget blueprint as a placeholder.
Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: "This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might."
The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.
A vote on the measure in the House could come on Friday.
In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.
In the parlance of Capitol Hill, many of the Democrats' proposals were "messaging amendments," intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.
As the Senate plowed through its work on Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans.
"This is our opportunity to keep our campaign promise," said Senator Roger Wicker, Republican of Mississippi. "This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences."
Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, "we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution."
Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.
Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time.
"But I don't see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month," she said. "I just don't see that as being feasible." (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)
As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next.
The Senate Democratic leader, Chuck Schumer of New York, called the Republicans' repeal plan "irresponsible and rushed" and urged them to halt their push to unravel the law.
"Don't put chaos in place of affordable care," he said.
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A Senate Vote-a-Rama Primer, in Case You Plan to Sleep Tonight
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November 8, 2012 Thursday
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With the re-election of President Obama, the sweeping federal health care legislation signed into law in 2010 has survived what most experts would agree was its last major challenge after last June's Supreme Court decision. By 2014, health insurance companies will be expected to offer coverage to everyone, regardless of an individual's health status, and sell policies through newly created state marketplaces aimed at making insurance more affordable and easier to obtain.
''I would say that really any doubt about whether implementation is going to go forward has now been removed,'' said Ralph S. Tyler, a former Maryland state insurance commissioner who is now a lawyer at the law firm Venable. ''So the focus really is not if, but how.''
Employers, health insurers and state regulators are now awaiting rules and regulations that will help them put into effect numerous provisions affecting what kind of coverage they must offer to workers or make available to people who buy individual policies. Many states, especially those led by Republicans opposed to the law, must also decide quickly whether they plan to operate their own insurance exchanges, where individuals choose among insurers, or let the federal government run them.
Much of this will become clear over the next three months, said Mark T. Bertolini, chairman and chief executive of Aetna, a large health insurer. As the insurers continue to prepare, they will try to persuade federal and state officials to make changes they say may be necessary, like adjusting how much they can charge people based on their age. ''There's going to be a lot more information about what needs to be done to make the Affordable Care Act work,'' he said.
But those affected by the new law are no longer holding their breath to see whether a Republican president would attempt a repeal, many observers said. ''There were a number of companies that had to plan for contingencies,'' said Les Funtleyder, the health care fund manager for Poliwogg, a private equity and hedge fund. But with much less uncertainty over whether the health care law appears to be going forward, he said, ''Companies can plan, which is actually pretty important.''
Hospital systems and doctors' groups are also less likely to delay efforts to find new ways of delivering better care more cheaply to patients, said Chas Roades, who leads research for the Advisory Board Company, a hospital consultant. ''A lot of the fence-sitting behavior that we've seen over the last year will end,'' he said.
With the Senate still in Democratic control, many concerns about whether Congress could successfully block full deployment of the law have also been muted, said Helen B. Darling, chief executive of the National Business Group on Health, which represents employers that provide health coverage to their workers. ''We will have a reinforcement of the Senate side of many of the provisions of the Affordable Care Act,'' she said.
Still, the so-called fiscal cliff, which will force Congress to deal with the federal budget deficit, leaves some doubt about the availability of financing for important provisions of the law, like the expansion of Medicaid and federal subsidies to help low-income individuals buy coverage in the exchanges.
''The fiscal cliff is clearly going to impact funding,'' said Michael Sachs, chief executive of Sg2, a health care analytics and consulting company. ''There's a very strong sense that there could be a possible delay in implementation'' of the exchanges and the Medicaid expansion, he said.
Major hospital stocks rose by 10 percent Wednesday, buoyed by the prospects of newly insured patients, while insurers, drug makers and device makers' stocks were all down, mirroring a dip in the broader stock market. REED ABELSON and KATIE THOMAS
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August 25, 2013 Sunday
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Sunday Dialogue: Blocking Health Reform
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Readers discuss Republican efforts to undercut Obamacare.
To the Editor:
For three years now, Democrats have implored states to develop health insurance exchanges, while Republicans have tried equally hard to block them. They will soon open, but in 33 states without their own, people will be served by a federal exchange.
Exchanges are insurance ''stores'' for individuals and small employers. They will offer four standardized levels of coverage -- platinum, gold, silver and bronze -- beginning January 2014, when much of the Affordable Care Act takes effect. Exchanges will also determine whether uninsured households are poor enough to qualify for Medicaid (free) or, if earning above the federal poverty line, for premium subsidies.
How will these exchanges improve health insurance? First, they will provide individual consumers something new: one-stop shopping with a side-by-side comparison of health plans. By standardizing coverage, patient cost-sharing, pricing, quality and service metrics, exchanges make informed choice of health plans easy.
Second, they will steer competition in socially beneficial directions. By empowering price-sensitive shoppers with information, they will put pressure on premiums. This can be further enhanced by the exchange's own effort, à la Walmart, to press health plans to improve price, quality and service in return for ''shelf space'' -- that is, access to the stores' customers.
Mitt Romney, the Republican standard-bearer in 2012, was so smitten with this conservative policy tool that as governor he made exchanges the centerpiece of Massachusetts's landmark health reform. It remains very popular here.
So why do most Republican politicians now oppose exchanges? Arguing that Obamacare is a fiasco and that the federal government will mismanage exchanges, Republicans plan to campaign on health reform's failure. By blocking states from developing their own exchanges and threatening to defund the federal exchange, they hope to make their own dire prediction come true.
JON KINGSDALE Boston, Aug. 19, 2013
The writer, managing director of the Wakely Consulting Group, helped establish the exchanges in Massachusetts.
Readers React
Having watched this continuing controversy over the Affordable Care Act, I've come to believe that what so bothers, and even terrifies, Republicans is that this plan could both work and become popular. If that comes to pass, they will be seen as obstructionists and the party that cares little for the health and well-being of average Americans.
If the G.O.P. is so sure that the health care law will be a fiasco, wouldn't a better strategy be to just let this disaster happen and then say ''we told you so, but you wouldn't listen''?
By continuing to rail against the health care law, the Republicans seem far from certain that the law will fail. Better to kill it now and not run the risk of its success.
DENNIS BLAKESLEE Madison, Wis., Aug. 21, 2013
There are two key reasons the insurance exchanges are likely to get off to a rocky start. First, the Affordable Care Act was passed during a brief period of Democratic supremacy over almost universal Republican opposition. Republicans have no interest in the success of what they call Obamacare. They control many of the levers of government and can do much to impede the health law.
Second, this complex law relies on persuading young people to take the positive step to buy insurance that has been heavily overpriced for them in order to underprice insurance for older people. The stick to encourage them to sign up is a trivial fine starting at $95. These are the same young people who are already burdened by Social Security and Medicare taxes to finance benefits for their elders that they do not expect to receive equally in their old age, and who often feel that health insurance is an unaffordable luxury.
The low initial penalties will most likely mean that while the old and the sick will quickly sign up for coverage, the young and the healthy will hang back, creating a death spiral of higher insurance premiums to cover the old and the sick, which will further discourage the young and the healthy from signing up.
JAMES G. RUSSELL Alexandria, Va., Aug. 21, 2013
The Affordable Care Act can succeed. Massachusetts proved that it can. A Republican governor and a Democratic Legislature passed health reform much like Obamacare. Yes, there were problems at the start. There always are when a complex law is put into effect. But business, labor, medical professionals and other organizations worked together to solve them.
Rollout of the Affordable Care Act will not be problem-free. But with cooperation, those problems, too, can be solved.
Unfortunately, opponents of the law are pursuing a destructive line of attack. Some state legislators are barring administrators from doing anything to carry out the law. Some members of Congress seem ready to close the government or to send the country into fiscal default in their effort to deny funding for health reform.
Many problems will be caused not by the admittedly complicated new law but by those officials who are recklessly trying to make the law fail and who seem to have forgotten that law-abiding citizens obey the law.
HENRY J. AARON Washington, Aug. 21, 2013
The writer is a vice chairman of the executive board of the D.C. Health Exchange and a senior fellow at the Brookings Institution.
All members of Congress enjoy the benefits of a health insurance exchange, where they and their families can shop for heavily tax-subsidized private health insurance. Employees of enterprises that sponsor health insurance also enjoy the benefit of such exchanges. The state-based insurance exchanges called for in the Affordable Care Act are no different. I cannot see any harm in them.
It is puzzling why Republicans now busy themselves trying to sabotage the implementation of exchanges for the individual and small-group markets. It is all the more puzzling because Senator Tom Coburn proposed a bill in May 2009 that called for insurance exchanges, as did earlier Republican bills in the 1990s. They did so because exchanges make good economic sense.
UWE REINHARDT Princeton, N.J., Aug. 21, 2013
The writer is a professor of economics and public affairs, Princeton University.
I have some direct experience using the Massachusetts health exchanges. I have found that they offer only very expensive options to those over 50 who do not qualify for subsidies. If someone needs an expensive prescription drug, that adds even more to the cost. I will admit that the plans require no waiting period, but the Massachusetts exchanges have done nothing to make plans affordable to those not relying on government handouts.
JOHN O'REILLY Cambridge, Mass., Aug. 21, 2013
The writer is a benefits consultant.
I have had a small company for 35 years. Up until 15 years ago, we paid the health care premiums for all employees. Then the insurance companies began raising rates, making this impossible. One year the rate increase was 39 percent. Currently only 4 of our 10 employees can afford the company insurance.
Now we have been notified that our rates for 2014 will be reduced 11 percent to 15 percent. And those who cannot afford that will be helped to enroll in the exchanges under the Affordable Care Act. How can anyone think that this is not the direction our country should be taking?
PAT HURD Chandler, Ariz., Aug. 21, 2013
The Affordable Care Act and the health insurance exchanges are making important repairs to our broken system, and we certainly shouldn't go back to the old system. But the law still leaves insurance companies in charge: with high premiums, high deductibles and co-payments, and too much control over which doctors or hospitals we can go to and what care we get.
We can do better. Instead of patchwork repairs, we can cover everyone, provide better coverage and save billions. How? Through publicly sponsored, single-payer health coverage, like an improved version of Medicare but for everyone.
Congress is nowhere near accepting that. But many states are more forward-looking. Under the health care law, states can build alternative systems. Vermont has enacted a law to build a single-payer system.
The country must not go backward, and the states can move us forward.
RICHARD N. GOTTFRIED New York, Aug. 21, 2013
The writer, a member of the New York State Assembly, is chairman of its Health Committee and the sponsor of a single-payer bill.
As a freelance writer and editor, I am one of the people the Affordable Care Act was supposed to help, but I don't foresee its insurance exchanges doing that.
I buy health insurance through a group of self-employed people, so I already get ''one-stop shopping with a side-by-side comparison of health plans.'' That means I get an informed choice among several increasingly costly and inadequate for-profit plans. I now pay more for a high-deductible plan (''bronze'') that covers next to nothing than I did for partial coverage (''silver'' or ''gold'') in 2009.
Maybe Obamacare's subsidies will help, but we don't know yet how much they'll be. We'd be much better off with Medicare for everyone than with this Rube Goldberg scheme written to satisfy the insurance lobby.
STEVEN WISHNIA
New York, Aug. 21 2013
I am half of a married couple in our mid-50s. We have never had a medical issue, don't smoke, don't drink, don't take drugs -- prescription or otherwise -- and take care with our diet and exercise. We have advanced degrees in business and are self-employed. And uninsured.
Every couple of years, we try to find a health insurance policy to buy. The process is such a tangle of indecipherable blather, impossible-to-compare features and insane costs that we abandon the effort. Affordability is not the issue; horror at the ridiculously inflated prices -- well documented in The Times -- is.
I applaud what Mitt Romney and Mr. Kingsdale accomplished in Massachusetts. I wish that President Obama's original vision for Obamacare hadn't been obliterated by our can't-do Congress. It will take our country that much longer to work out the kinks.
In the meantime, the exchanges begin to create a relationship between cost and service. They create an opportunity for consumers to avoid needless markups and enjoy premium service. Call me giddy with anticipation -- Obamacare is making me feel great already.
GIOVANNA FINAMORE Miami Beach, Aug. 21, 2013
The new insurance exchanges will not only improve health insurance, as Mr. Kingsdale notes, but they will also provide compelling evidence of how states perform as laboratories of democracy. Each state exchange will be different, in transparent and measurable ways. Even the federal exchanges will differ across states, depending on how cooperative each state is, how many insurers are operating in the state and how many people in the state lack insurance, among other things.
By systematically collecting information about each state exchange, and then separating out the factors that are beyond the governors' and legislators' control, we can hold state political leaders accountable. We can also figure out which insurance exchange designs work best, so that governors and state legislators who want to help their citizens can improve their exchanges in the years ahead.
TOM BAKER Philadelphia, Aug. 21, 2013
The writer is a professor of law and health sciences at the University of Pennsylvania Law School and the co-director of the Health Insurance Exchange Research Group of Penn's Leonard Davis Institute of Health Economics.
The Writer Responds
Given the depth of the partisan divide over health reform, voters will likely be asked to render a verdict on the Affordable Care Act in 2014. While the chances of defunding it before then are slim, dramatic opposition now will influence that verdict in several ways.
First, as Mr. Aaron suggests, unremitting opposition actually impedes implementation. In Michigan, for example, even the Republican governor could not persuade Republican state legislators to support development of their own exchange. Apparently, they prefer to oppose any health insurance exchange rather than champion one run by their own state under Republican rule.
Second, as Mr. Russell points out, the success of popular insurance market reforms depends ''on persuading young people to ... buy insurance.'' Our success in Massachusetts suggests that this behavior was due far more to popular acceptance of the notion that everyone (who can afford it) should buy coverage than to any penalty for not doing so. This is a mind-set, not a cost-benefit decision.
For the first six months under Massachusetts' mandate, there was no penalty, and even now most tax filers without insurance are exempt from fines. By castigating reform in advance, opponents discourage enrollment -- who feels morally obliged to sign up for failure?
Third, as the contrasting experiences of Mr. O'Reilly and Mr. Hurd suggest, there will be plenty of insurance stories in 2014, good and bad. We are naturally inclined to note and accept evidence that reinforces our prejudices, and to dismiss or undervalue facts that do not fit our assumptions. Democrats and Republicans are competing now to sensitize voters to the narratives that each party will repeat in the next election.
The shame on Republicans is not that they fight for their preferred solution, but that they fight any solution. As Mr. Reinhardt suggests, they even oppose their own solutions.
JON KINGSDALE Boston, Aug. 23, 2013
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October 3, 2016 Monday
Late Edition - Final
Next President Likely to Shape Health Law Fate
BYLINE: By ROBERT PEAR
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WASHINGTON -- The fierce struggle to enact and carry out the Affordable Care Act was supposed to put an end to 75 years of fighting for a health care system to insure all Americans. Instead, the law's troubles could make it just a way station on the road to another, more stable health care system, the shape of which could be determined on Election Day.
Seeing a lack of competition in many of the health law's online insurance marketplaces, Hillary Clinton, President Obama and much of the Democratic Party are calling for more government, not less.
The departing president, the woman who seeks to replace him and nearly one-third of the Senate have endorsed a new government-sponsored health plan, the so-called public option, to give consumers an additional choice. A significant number of Democrats, for whom Senator Bernie Sanders spoke in the primaries, favor a single-payer arrangement, which could take the form of Medicare for all.
Donald J. Trump and Republicans in Congress would go in the direction of less government, reducing federal regulation and requirements so insurance would cost less and no-frills options could proliferate. Mr. Trump would, for example, encourage greater use of health savings accounts, allow insurance policies to be purchased across state lines and let people take tax deductions for insurance premium payments.
In such divergent proposals lies an emerging truth: Mr. Obama's signature domestic achievement will almost certainly have to change to survive. The two parties agree that for too many people, health plans in the individual insurance market are still too expensive and inaccessible.
''Employer markets are fairly stable, but the individual insurance market does not feel stable at all,'' said Janet S. Trautwein, the chief executive of the National Association of Health Underwriters, which represents more than 100,000 agents and brokers who specialize in health insurance. ''In many states, the individual market is in a shambles.''
Mr. Obama himself, while boasting that 20 million people had gained coverage because of the law, acknowledged in July that ''more work to reform the health care system is necessary.''
''Too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain uninsured,'' Mr. Obama wrote in The Journal of the American Medical Association.
The marketplace faces a major test in the fourth annual open enrollment season, which starts on Nov. 1, a week before Election Day. In many counties, consumers will see higher premiums and fewer insurers, as Aetna, Humana and UnitedHealth have curtailed their participation in the exchanges, and many of the nonprofit insurance cooperatives, created with federal money, have shut down.
Mr. Trump has said that Congress must ''completely repeal Obamacare,'' and Republicans in Congress have repeatedly tried to do so. But parts of the law appear to be here to stay. One such provision, now widely accepted, says that insurers cannot deny coverage because of a person's medical condition or history.
For their part, many Democrats are clamoring for a public insurance option, as they did nine years ago.
''Supporters of the public option warned that private insurance companies could not be trusted to provide reliable coverage or control costs,'' said Richard J. Kirsch, who led a grass-roots organization that fought for passage of the Affordable Care Act in 2009 and 2010. ''The shrinking number of health insurers is proof that these warnings were spot on.''
On Sept. 15, Senator Jeff Merkley, Democrat of Oregon, introduced a resolution calling for a public option. The measure now has 32 co-sponsors, including the top Senate Democrats: Harry Reid of Nevada, Chuck Schumer of New York and Richard J. Durbin of Illinois.
''You need competition to make the exchanges successful,'' Mr. Merkley said in an interview. ''A public option guarantees there's competition in each and every exchange around the country.''
As they did before the Affordable Care Act was enacted, insurance lobbyists are mobilizing to kill the public option. The main trade group for the industry, America's Health Insurance Plans, says it would do nothing to stabilize the exchanges, and in an urgent ''action alert,'' the group asked member companies to lobby against Mr. Merkley's resolution.
Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said the Democrats' public option plan would compound the problems it seeks to solve.
''Obamacare exchanges are collapsing because of federal mandates and a lack of flexibility,'' Mr. Alexander said. ''We need to give states more flexibility and individuals more choices so more people can buy low-cost insurance.''
Mr. Trump would replace the Affordable Care Act with an assortment of conservative policies, including some that are similar to ideas favored by House Republicans and by think tanks like the Heritage Foundation or the American Enterprise Institute. But Democrats and some Republicans say that Mr. Trump has not laid out a comprehensive, coherent alternative to the Affordable Care Act.
Mr. Trump would eliminate the requirement that most Americans carry health insurance. He would encourage the sale of insurance across state lines, in a bid to increase competition. And he would convert Medicaid, now an open-ended entitlement, into a block grant, giving each state a lump sum of federal money to provide health care to low-income people.
The basic structure of the Affordable Care Act looked promising to private insurers. The government, in effect, required consumers to buy their products and provided subsidies to help defray the cost, under an arrangement that had few precedents in other industries.
A public option could take market share from private insurers, so it is no surprise they would oppose it. But insurers say the public option would not hold down medical costs, which they describe as the main engine driving up premiums. Moreover, insurers say that the government would have an unfair advantage if it both regulates and competes with private plans.
For some people, the subsidies have proved inadequate. People with annual incomes less than two and half times the poverty level (less than $29,700 for an individual) receive the most generous subsidies and have signed up in large numbers.
But enrollment figures suggest that higher-income people who receive smaller subsidies or none at all have not seen insurance as such a bargain.
''The insurance exchanges have enrolled more than 80 percent of the potential exchange population with incomes below 150 percent of the federal poverty level,'' said Caroline F. Pearson, a senior vice president of Avalere, a health policy consulting company. But, she added, they have enrolled only 17 percent of potential customers with incomes from three to four times the poverty level ($35,640 to $47,520 for an individual).
Andrew M. Slavitt, the acting administrator of the Centers for Medicare and Medicaid Services, said the administration was taking steps to ensure ''a stable, sustainable marketplace'' -- by increasing payments to insurers for ''high-cost enrollees'' and by curbing any abuse of ''special enrollment periods'' by people who sign up for coverage after they become sick. In addition, federal officials are redoubling efforts to sign up young adults.
Dr. John W. Rowe, who was the chief executive of Aetna from 2000 to 2006 and the president of Mount Sinai Medical Center in New York before that, predicted that ''the insurance market will stabilize in two or three years.''
''We are not in a death spiral,'' Dr. Rowe said. ''If this were a patient, I would say that he's not in intensive care, but he's still in the hospital and requires careful monitoring.''
But that does not mean the act will heal on its own, said Sara Rosenbaum, a professor of health law and policy at George Washington University.
''Even the most ardent proponents of the law would say that it has structural and technical problems that need to be addressed,'' she said. ''The subsidies were not generous enough. The penalties for not getting insurance were not stiff enough. And we don't have enough young healthy people in the exchanges.''
URL: http://www.nytimes.com/2016/10/03/us/politics/obama-health-care-act.html
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January 18, 2017 Wednesday
Late Edition - Final
Pressure on G.O.P. as Repeal May Strip Millions of Coverage
BYLINE: By ROBERT PEAR; Jennifer Steinhauer and Thomas Kaplan contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1345 words
WASHINGTON -- Eighteen million people could lose their insurance within a year and individual insurance premiums would shoot upward if Congress repealed major provisions of the Affordable Care Act while leaving other parts in place, the nonpartisan Congressional Budget Office said on Tuesday.
A report by the office sharply increases pressure on Republicans to come up with a comprehensive plan to replace the health care law. It is likely to doom the idea of voting to dismantle the 2010 health law almost immediately, with an effective date set sometime in the future while Congress works toward a replacement.
If nothing followed the gutting of President Obama's signature domestic achievement, the budget office said, 32 million people could lose their health insurance by 2026, and premiums in the individual insurance market could double. Senator Susan Collins, Republican of Maine, showed the unease of some in her party when she said that repealing the health care law and delaying a replacement could send insurance markets into ''a death spiral.''
She detected ''a growing consensus among members of both the Senate and the House that we must fix Obamacare and provide reforms at nearly the same time that we repeal the law,'' she said on the Senate floor on Tuesday.
The new budget office report, issued after a weekend of protests against repeal, will only add to the headaches that President-elect Donald J. Trump and congressional Republicans face in their rush to take apart Mr. Obama's health law as they try to replace it with a health insurance law more to their liking.
Republicans cautioned that the report painted only part of the picture -- the impact of a fast repeal without a Republican replacement. Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee, said the numbers represented ''a one-sided hypothetical scenario.''
''Today's report shows only part of the equation -- a repeal of Obamacare without any transitional policies or reforms to address costs and empower patients,'' he said. ''Republicans support repealing Obamacare and implementing step-by-step reforms so that Americans have access to affordable health care.''
Congress last week approved a budget that clears the way for speedy action to repeal the health care law. The votes were 51 to 48 in the Senate and 227 to 198 in the House.
But Republicans have yet to agree on a replacement bill, and existing Republican plans, like one drafted by Representative Tom Price of Georgia, who was selected as Mr. Trump's secretary of health and human services, have yet to be scrutinized by the budget office. The office provides Congress with the official projections of legislative costs and impact that lawmakers use to formulate policy.
''No wonder President-elect Trump realizes that repeal without replace is the real disaster,'' said Senator Chuck Schumer of New York, the Democratic leader. ''No wonder he has admonished the Congress not to do plain repeal.''
Republicans now have two powerful reasons to ''repeal and replace'' together: They hope to protect about 20 million Americans who have gained coverage under the law. And they want a politically acceptable judgment from the Congressional Budget Office on the effects of their alternative.
Mr. Trump's statement last week that a replacement plan should go hand in hand with repeal efforts had already ignited a sense of urgency among Republicans on Capitol Hill. Over the weekend Mr. Trump said he was close to completing a plan to replace the Affordable Care Act with the goal of ''insurance for everybody,'' but congressional aides said Tuesday that they had not seen an actual proposal.
Republican congressional leaders are trying to put together a plan that could pass muster with the Trump team and also win approval in the Senate under fast-track procedures that would neutralize the threat of a Democratic filibuster.
House Speaker Paul D. Ryan and Senator Mitch McConnell of Kentucky, the Republican leader, met last week with Mr. Price to hash out alternatives, and they have been in close contact with the relevant committee leaders and staff members to begin hammering out ideas that could come into relief at the end of the month, when Republicans have their annual policy retreat.
Stephen Miller, a former Senate press aide and the incoming senior White House adviser for policy, who has been particularly aggressive in presenting himself as the voice of Mr. Trump on all policy matters, has pushed the notion that a plan should move quickly and in tandem with a replacement measure, rather than in a series of smaller bills, congressional aides said.
The repeal legislation analyzed by the budget office would have eliminated tax penalties for people who go without insurance. It would also have eliminated spending for the expansion of Medicaid and subsidies that help lower-income people buy private insurance. But the bill preserved requirements for insurers to provide coverage, at standard rates, to any applicant, regardless of pre-existing medical conditions.
''Eliminating the mandate penalties and the subsidies while retaining the market reforms would destabilize the nongroup market, and the effect would worsen over time,'' the budget office said.
The office said the estimated increase of 32 million people without coverage by 2026 resulted from three changes: About 23 million fewer people would have coverage in the individual insurance market. Roughly 19 million fewer people would have Medicaid coverage. And there would be an increase in the number of people with employment-based insurance that would partially offset those losses.
The estimates by the budget office are generally consistent with projections by the Obama administration and by insurance companies.
In its report, the budget office said that repealing selected parts of the health care law -- as specified in the earlier Republican bill -- would have adverse effects on insurance markets.
In the first full year after the enactment of such a bill, the office said, premiums would be 20 percent to 25 percent higher than under current law.
Repealing the penalties that enforce the ''individual mandate'' would ''both reduce the number of people purchasing health insurance and change the mix of people with insurance,'' as younger and healthier people with low health costs would be more likely to go without insurance, the budget office said.
The Republican bill would have eliminated the expansion of Medicaid eligibility and the subsidies for insurance purchased through Affordable Care Act marketplaces, after a transition period of about two years.
Those changes could have immediately increased the number of uninsured by 27 million, a number that would gradually increase to 32 million in 2026, the budget office said.
Without subsidies, the budget office said, enrollment in health plans would shrink, and the people who remained in the individual insurance market would be sicker, with higher average health costs. These trends, it said, would accelerate the exodus of insurers from the individual market and from the public marketplaces.
As a result, it said, about half of the nation's population would be living in areas that had no insurer participating in the individual market in the first year after the repeal of marketplace subsidies took effect. And by 2026, it estimated, about three-quarters of the population would be living in such areas.
While writing the Affordable Care Act in 2009 and 2010, lawmakers continually consulted the Congressional Budget Office to understand the possible effects on spending, revenue and insurance coverage. The current director of the budget office, Keith Hall, who signed the report issued on Tuesday, was selected and appointed by Republican leaders of Congress in 2015.
The latest report was requested by Mr. Schumer and two other Democrats, Senators Ron Wyden of Oregon and Patty Murray of Washington.
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URL: http://www.nytimes.com/2017/01/17/us/politics/congressional-budget-office-affordable-care-act.html
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Many customers of Sunshine Health and Life Advisors in Miami would be affected by changes to the Affordable Care Act. (PHOTOGRAPH BY ANGEL VALENTIN FOR THE NEW YORK TIMES) (A16)
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May 6, 2013 Monday
About Half of Adults Lacked Adequate Health Coverage in 2012
BYLINE: ANN CARRNS
SECTION: YOUR-MONEY
LENGTH: 437 words
HIGHLIGHT: But a new Commonwealth Fund report finds that more young adults were insured, probably as a result of the health care law.
About half of United States adults ages 19 to 64 didn't have health insurance for at least part of last year or were underinsured, a new reportfrom the Commonwealth Fund says.
The fund, a private nonprofit organization that finances research into health care and health policy issues, conducts the health insurance survey every two years.
One bright spot, the report found, is that the proportion of young adults without health insurance fell significantly over the last two years, probably because of a provision of the Affordable Care Act that allows young adults to stay on their parents' health plans until age 26. The rule took effect in September 2010.
Nearly eight out of 10 (79 percent) young adults reported that they were insured, up from 69 percent in 2010. That marks "an abrupt reversal in a decadelong climb" in the number of uninsured young adults, the report said.
Uninsured rates for other age groups, however, either rose or stayed the same. About half of adults ages 19 to 64 didn't have health insurance for all of 2012 or were underinsured, meaning that they had insurance but struggled to pay for medical costs anyway.
At the time of the survey, about 30 percent said they were uninsured or were insured but hadn't been at some point during the year. Another 16 percent had insurance, but had such high out-of-pocket medical costs relative to their income that they were effectively uninsured.
The survey also found that people are increasingly skipping needed health care because they can't afford it (about 43 percent answered yes to that question). That's up from 37 percent in 2003, the report noted.
The report found that about two out of every five adults had trouble paying medical bills last year or were paying off medical debt over time, and that many of those struggling with medical debt (42 percent) said they had received a lower credit rating as a result.
The results are based on a telephone survey of 4,432 adults by Princeton Survey Research Associates International from April 25 to August 19, 2012. The margin of sampling error is plus or minus 2 percentage points.
The report is the last one the fund will conduct before the major provisions of the Affordable Care Actare scheduled to go into effect, in January 2014.
Did you have a gap in insurance coverage last year? Do you expect the health care law to help provide you with coverage?
Shorter Forms for Coverage Under New Health Law
Breast Pump Coverage Under New Law Varies In Practice
Health Insurance Deductibles Doubled in 7 Years, Study Finds
Workers' Share of Health Costs Is Likely to Continue Rising
Visiting the Doctor, Virtually
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June 28, 2012 Thursday
Romney's Call to Arms
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 506 words
HIGHLIGHT: In response to the Supreme Court's health care ruling, the candidate ran through his usual talking points.
Mitt Romney looked a little shaken when he faced the cameras this morning to comment on the Supreme Court's decision upholding the Affordable Care Act. Having thrown out his preferred speech thanking the court for rejecting the law, he didn't seem to have much of a backup other than a call to arms for conservative voters.
To start off by saying the court only found the law constitutional, and didn't proclaim it a good law, was almost laughable The only point of this legal exercise was to determine whether the law was constitutional, and if it had gone the other way, you can bet Mr. Romney would have accused President Obama of breaking trust with the founders and the nation's sacred charter. Although Justice Antonin Scalia might disagree, the role of the court is not to determine whether policies and law are "good," and Chief Justice John Roberts provided a succinct lesson to that point that Mr. Romney might want to study.
"The Court does not express any opinion on the wisdom of the Affordable Care Act," Mr. Roberts wrote. "Under the Constitution, that judgment is reserved to the people."
Now that the matter is squarely in the people's hands, and out of the courts', Mr. Romney's task will be trying to persuade them that he has a better idea. Voters don't seem to care much that he had precisely the same idea when he was governor of Massachusetts, but they will start to show concern if he doesn't come up with more than the same tired talking points he ran through today.
Much of what he said, and what he has said all along, is factually untrue. The law doesn't add "trillions to our deficits and to our national debt." It actually lowers the deficit, as the Congressional Budget Office has repeatedly noted. There is no evidence that it is keeping businesses from hiring. It won't force 20 million Americans to lose their insurance - not just a made-up number but also a made-up concept. People who have insurance now will be able to keep it, as the president said today.
What it will do, and what Mr. Romney never mentions, is provide coverage for nearly 30 million Americans who lack it. That group, totally off Mr. Romney's radar screen, didn't come up in his speech today, except indirectly in an exceedingly vague line: "We also have to assure that we do our very best to help each state in their effort to assure that every American has access to affordable health care."
How, precisely? Apparently Americans will only find out after he is elected. The answer is particularly needed given his plan to severely cut Medicaid and other aid to states, as part of the Ryan budget that he has embraced. Those cutbacks will make it much harder for states to offer insurance or even basic care to the poor and the uninsured.
Mr. Romney was certainly correct in saying that "this is a time of choice for the American people," but apparently he does not want it to be an informed choice.
Roberts Hits the Reset Button
Painting Romney With the Bush Brush
Five-Four
Opinion Report: America's No. 1 Foe
Opinion Report: Supreme Health
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September 30, 2016 Friday
Late Edition - Final
Insurers Got Funds Meant for Treasury, Auditors Say
BYLINE: By ROBERT PEAR.
Follow Robert Pear on Twitter @ropear.
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 3
LENGTH: 759 words
WASHINGTON -- Federal auditors ruled on Thursday that the Obama administration had violated the law by paying health insurance companies more than allowed under the Affordable Care Act in an effort to hold down insurance premiums.
Some of the money was supposed to be deposited in the Treasury, said auditors from the Government Accountability Office.
The administration ''ignored the statutory requirement to collect funds for the Treasury,'' even though the requirement was expressed in ''explicitly mandatory language,'' the accountability office said in a legal opinion.
The Obama administration had defended its interpretation of the law, saying the payments to insurers were needed to help moderate increases in premiums under the Affordable Care Act.
Seven Republican members of Congress, all opposed to the health law, had asked for the legal review and welcomed its findings. ''The Obama administration can no longer take money from taxpayers to bail out Obamacare,'' said Senator John Barrasso, Republican of Wyoming.
The Government Accountability Office is widely regarded as an authority on the legality of federal spending. It does not have enforcement power, but its rulings are usually followed by federal officials, and Congress relies on its work in writing laws and supervising federal agencies.
Matt Inzeo, a spokesman for the Department of Health and Human Services, said the administration ''strongly disagrees'' with the opinion. The administration said it had discretion to decide how money should be allocated between insurers and the Treasury when the total amount available was -- as in this case -- less than expected.
Four and a half months before Thursday's ruling, a federal district judge here ruled that the Department of Health and Human Services had illegally spent billions of dollars on a part of the health law that helps low-income people pay deductibles and other out-of-pocket costs for hospital care and doctors' services.
In recent weeks, state insurance commissioners have approved rate increases of 25 percent or more for many insurers in 2017. Insurers say that premiums would be even higher without the extra payments from the federal government.
At issue is a program that collects fees from most insurers and uses the money to help pay high-cost claims for sicker people. The purpose of this temporary ''reinsurance program'' is to stabilize premiums and to encourage insurers to participate in markets under the health care law.
The 2010 law stipulates that some of the money ''shall be deposited into the general fund of the Treasury of the United States and may not be used for the program'' to provide financial assistance to insurance companies.
The auditors found that the Obama administration had flouted this requirement. Under the law, the government was supposed to collect a total of $25 billion from 2014 to 2016 and deposit $5 billion of that in the Treasury.
The administration set the amount to be contributed by each insurance company, but the total collections fell short of the amounts specified in the law. So the administration allocated almost all the money to insurers, ''resulting in the deposit of no amounts in the Treasury,'' the accountability office said.
The administration ''may not use amounts collected for the Treasury to make'' payments to insurance companies, said the ruling, signed by Susan A. Poling, the general counsel of the G.A.O.
The law ''very clearly directs'' the secretary of health and human services to deposit certain amounts in the Treasury, Ms. Poling said. ''The fact that H.H.S.'s collections ultimately fell short of the projected amounts does not alter the meaning of the statute,'' she added.
The ruling by the G.A.O. does not directly affect a separate program with a similar purpose that was meant to limit the financial losses of insurance companies under the Affordable Care Act. But it could complicate efforts by the administration to negotiate a settlement with various insurance companies that have sued the government, saying they received much less money than they were promised under this program.
Under the reinsurance program, the government was supposed to collect $12 billion in 2014, but actual collections totaled $9.7 billion. Courts have held that when funds fall short of expectations, a federal agency should try to achieve the ''original statutory scheme'' as much as possible.
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URL: http://www.nytimes.com/2016/09/30/business/obama-affordable-care-act.html
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March 25, 2017 Saturday
The New York Times on the Web
How the Health Care Vote Fell Apart, Step by Step
BYLINE: By KATIE ROGERS
SECTION: Section ; Column 0; Washington; Pg.
LENGTH: 809 words
WASHINGTON -- After several days of dramatic back and forth between President Trump and Republicans in Congress, House Republicans pulled a bill to repeal and replace the Affordable Care Act, delivering the president a staggering defeat in his first high-profile legislative effort.
That's quite a turn of events. Let's break them down.
What happened?
Republican leaders shelved the legislation on Friday afternoon -- shortly before an expected vote -- after House members spent days pushing for concessions on the replacement proposal, called the American Health Care Act. A day before, after the vote was postponed, Mr. Trump demanded that a vote be held on Friday. But the bill was pulled as it looked as though it would fall shy of the 215 votes needed to pass the House.
Who decided to pull the bill? Mr. Trump and the House speaker, Paul D. Ryan, both said it was their decision.
''Ryan says that he advised Trump to pull the bill,'' Julie Hirschfeld Davis, a White House correspondent for The New York Times, wrote in a live analysis. ''Interesting, because Trump told us that he had directed Ryan to yank it. A lot of blame-shifting going on.''
How did the vote get derailed?
The proposal would have replaced the Affordable Care Act, known as Obamacare, with a system of age-based tax credits to purchase insurance coverage, and its provisions brought a divide between ultraconservative and moderate House Republicans into relief.
This is the gist: The most conservative members of the House didn't think that the American Health Care Act would go far enough to eradicate Obamacare, and moderates were concerned about an estimate by the nonpartisan Congressional Budget Office that 24 million Americans would be left without insurance.
Republican leaders bent to the will of the House Freedom Caucus, a group of about 30 hard-line members, agreeing to remove several federal mandates for minimum benefits, including mental health services and some maternity care. But this move still didn't go far enough to appease members of the caucus. And the concessions alienated several moderates.
How has President Trump reacted?
By blaming the Democrats.
In a phone call to The New York Times on Friday, Mr. Trump noted that no Democrats had pledged to support the bill, and that they would probably seek a deal once ''Obamacare explodes'' because of rising premiums and declining options. Speaking later to reporters in the Oval Office, he criticized Nancy Pelosi, the House minority leader, and Chuck Schumer, the top Senate Democrat.
''Now they own Obamacare,'' he said. ''They own it.''
Mr. Schumer fired back on Twitter.
Ultimately the #Trumpcare bill failed because of two traits that have plagued the Trump presidency: incompetence & broken promises. -- Chuck Schumer (@SenSchumer) March 24, 2017
Mr. Trump praised Mr. Ryan for working ''very, very hard.'' He summed up this exercise in legislative failure as a ''very interesting experience.''
But this bill was the first major test of Mr. Trump's ability to corral members of Congress to fulfill his campaign promises, and it was a stunning failure. A president who has prided himself on his negotiation skills in the business world learned the limits of his sway in his new office.
What happens next?
The Affordable Care Act stays intact.
''We're going to be living with Obamacare for the foreseeable future,'' Mr. Ryan told reporters on Friday.
The president seemed to agree. ''It's enough already,'' said Mr. Trump, who has been president for just over two months. The Republicans will be moving on to tax reform, which Mr. Ryan said would be an uphill battle.
In the meantime, Democrats are rejoicing. For now.
Thanks @realDonaldTrump. I & many other Dems will fully take credit for defeating you. We will do it again whenever you push a stupid policy https://t.co/pWjeIyrdJA -- Ted Lieu (@tedlieu) March 24, 2017
Hey Republicans, don't worry, that burn is covered under the Affordable Care Act -- Senator Bob Menendez (@SenatorMenendez) March 24, 2017
How did we get here?
For at least the past year and a half, Mr. Trump had talked about quickly repealing and replacing the current health care law. It was a signature campaign promise.
Shortly after taking office, Mr. Trump shifted course, warning that it might take until 2018 to make sure it was done correctly.
But in this White House, a lot can change in a month, and Republicans unveiled the first version of their plan four weeks later. What followed was a series of quick changes to try to appease conservative and moderate House Republicans.
On Thursday, Mr. Trump sent a message to Republicans: Either vote to replace the Affordable Care Act, or leave it in place.
Clearly, that ultimatum backfired.
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URL: http://www.nytimes.com/2017/03/24/us/politics/guide-to-how-the-health-care-vote-fell-apart.html
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March 27, 2012 Tuesday
Opinion Report: The Anti-Injunction Act
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 115 words
HIGHLIGHT: A summary of what's on today's editorial page.
Secretary of State Hillary Rodham Clinton approved the resumption of military aid to Egypt, partly to protect the interests of American arms manufacturers.
During oral arguments on Monday, the Supreme Court justices showed their skepticism that the Anti-Injunction Act prohibits them from ruling on the merits of the Affordable Care Act.
Injured racehorses are often forced to run while drugged, to the great peril of both animals and jockeys.
Gov. Andrew Cuomo signed into law a major expansion of New York State's DNA database.
Opinion Report: Mohammed Merah
Opinion Report: Student Loans
Opinion Report: N.Y.P.D. Surveillance
Santorum's Super Tuesday Message: Romney Is a Liar
Opinion Report: Detroit
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The New York Times
March 1, 2015 Sunday
Late Edition - Final
The Phony Legal Attack on Health Care
BYLINE: By THE EDITORIAL BOARD
SECTION: Section SR; Column 0; Editorial Desk; EDITORIAL; Pg. 8
LENGTH: 915 words
On Wednesday, the Supreme Court will hear oral arguments in one of the most anticipated cases of the term: King v. Burwell, a marvel of reverse-engineered legal absurdity that, if successful, will tear a huge hole in the Affordable Care Act and eliminate health insurance for millions of lower-income Americans -- exactly the opposite of what the law was passed to do.
The central claim of the lawsuit, which was filed on behalf of four Virginians by a small group of conservative activists who have long sought to destroy Obamacare, is that the law does not allow tax-credit subsidies to be made available to anyone living in the 34 states whose health care exchanges are operated by the federal government, which stepped in when those states declined to set up their own.
This is, to put it mildly, baloney.
In the long, tangled history of the debate over the Affordable Care Act, no member of Congress ever indicated a belief that the law would work this way. To the contrary, the law explicitly provides for ''quality, affordable health care for all Americans.''
And it has accomplished a good deal of this goal: More than 11 million people now have coverage under the law, and more than eight in 10 of them qualify for subsidies. In other words, broad availability of the subsidies is central to the functioning of the act. Without them, it collapses.
But because of the opponents' purposefully blinkered reading of four words in the 900-page law the case is now before the Supreme Court.
The four words -- ''established by the State'' -- appear in a subsection of the law dealing with the calculation of tax credits. The law's challengers say this means that credits are available only in the 16 states that have set up their own exchanges.
The challengers did not innocently happen upon these words; they went all out in search of anything that might be used to gut the law they had failed to kill off once before, on constitutional grounds, in 2012. Soon after the law passed in 2010, Michael Greve, then chairman of the Competitive Enterprise Institute, which is helping to finance the current suit, said, ''This bastard has to be killed as a matter of political hygiene. I do not care how this is done, whether it's dismembered, whether we drive a stake through its heart, whether we tar and feather it and drive it out of town, whether we strangle it.''
After the challengers found the four-word ''glitch,'' as they initially called it, they worked backward to fabricate a story that would make it sound intentional. Congress, they claimed, sought to induce states to establish exchanges by threatening a loss of subsidies if they did not. (Not coincidentally, the challengers also traveled state to state urging officials not to set up exchanges, thus helping to create the very ''crisis'' they now decry.) Of course, if Congress intended to introduce a suicide clause into a major piece of federal legislation, it would have shouted it from the mountaintops and not hidden it in a short phrase deep inside a sub-sub-subsection of the law. So it is no surprise that no one involved in passing or interpreting the law -- not state or federal lawmakers, not health care journalists covering it at the time, not even the four justices who dissented in the 2012 decision that upheld the Affordable Care Act -- thought that the subsidies would not be available on federal exchanges.
Many legal observers were surprised that the court agreed to hear the case at all. But despite several justices' clear dislike for the health care law, it is hard to imagine how they could disregard their longstanding approach to interpreting statutes, which, as Justice Clarence Thomas wrote in a 1997 case, requires them to consider ''the language itself, the specific context in which that language is used, and the broader context of the statute as a whole.''
Reading the Affordable Care Act as a whole, it's clear that Congress meant to provide subsidies on both federal and state exchanges. For one thing, why establish a federal exchange that doesn't actually work? As an amicus brief submitted by a group of legal scholars put it, ''Congress does not write statutes to fail.''
And yet the challengers insist that their bizarre, noncontextual reading of the law is the only possible one. A majority of federal judges who have reviewed the case have thrown out this argument. So should the Supreme Court. Even if the court were to consider the law ambiguous, under its own precedent it must defer to an agency's reasonable interpretation of the statute's wording. Here, that agency is the I.R.S., which has issued a rule affirming that subsidies are available no matter who establishes the exchange.
The challengers disingenuously say that Congress can go back and change the wording, knowing full well that Republicans on Capitol Hill hate the law almost as much as they do. The states that currently rely on federally operated exchanges could set up their own, but many -- egged on by the challengers -- have already refused to do that.
Whatever legal games the challengers play, this case has never been more than a ginned-up, baseless attack on one of the most important pieces of social legislation of the last generation. The health of millions of Americans hangs in the balance. And now it is not even clear that the four plaintiffs have legal standing to bring the lawsuit.
So how did the suit get so far? That is an excellent question, and only the Supreme Court can answer it.
URL: http://www.nytimes.com/2015/03/01/opinion/sunday/the-phony-legal-attack-on-health-care.html
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(In Practice)
March 6, 2014 Thursday
More Than One Way to Buy a Plan
SECTION: US
LENGTH: 846 words
HIGHLIGHT: Private websites are offering alternatives to HealthCare.gov for buying health plans.
When the federal online marketplace for the Affordable Care Act stumbled out of the gate last fall, leaving would-be applicants unable to sign up for care or even to view their plans, three young programmers thought they might be able to help frustrated users. In October, they packaged reams of publicly-available data into a website, healthsherpa.com, that allowed users to immediately view exchange plans in their area. But the site was intended for research only; users still had to purchase them through the federal and state health exchanges or, in some cases, directly through insurers.
That changed last week, when the programmers - Michael Wasser, George Kalogeropoulos and Ning Liang - added functionality to their website that allows people to actually sign up for plans on their site, and joined a group of so-called Web brokers who offer a way to enroll in qualified health plans that they say is quicker and simpler than using the federal exchange.
"We're hoping that we're building an easier place to sign up for health insurance where you get the same exact results as you would on HealthCare.gov," said Mr. Wasser.
Mr. Wasser said the programmers were approached last fall, after they started their website, by Bryan Sivak, the chief technology officer for the Department of Health and Human Services. They made an agreement that would allow healthsherpa.com to integrate with elements of HealthCare.gov and sign individuals up for on-exchange plans, with subsidies.
The HealthSherpa team has since added two more employees and raised $1.1 million in seed funding. Their business model is similar to that of an insurance broker, since they will earn commissions from insurance companies when the individuals who use their site to sign up for coverage pay their premiums.
Mr. Wasser said it currently took users on the site about an hour to sign up for care. First, users enter their zip code to see a list of available plans in their area, which they can refine according to their age, family size and their preferred level of coverage. After selecting a plan, they are directed to a page on healthcare.gov, where they enter information to determine their eligibility for tax credits and cost-sharing reduction. Users are then directed back to healthsherpa.com to confirm and enroll.
"We're just working to try to find as many ways as we can to shorten the time it takes for people to sign up," said Mr. Wasser, who said he and his team would eventually like to reduce sign-up time to as little as 10 minutes.
So far, according to Mr. Wasser, several hundred people have started the application process on his website, and about 40 had completed the signup process - about a third of whom had applied for subsidies.
The Department of Health and Human services has about 30 agreements with Web brokers intended to enable the sites to offer consumers options outside the federal exchange to sign up for health care under the Affordable Care Act.
"By strengthening the multiple channels to enroll in quality, affordable coverage through the Marketplace, we are offering Americans more options to purchase new coverage," said Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services.
But the sites have offered varying levels of functionality, in part because of technical issues in determining users' eligibility, which is still done through the federal system.
"The reason we're not seeing more web brokers doing this process online right now is because the eligibility system is still being fixed," said Claire McAndrew, the private health insurance director of FamiliesUSA, a health care consumer advocacy group.
GoHealth.com, for example, has been signing up users for exchange plans with subsidies using a call center since November. And last month, GetInsured.com announced the launch of a web-only enrollment process for plans under the Affordable Care Act - something the company had initially planned on offering sooner. As HealthSherpa does, it now directs customers to HealthCare.gov and then back to its own sites during the process.
The website eHealth can sign people up for plans, but the company's C.E.O., Gary Lauer, recently told CNBC it had been unable to process subsidies.
The private exchanges say that their tools make it easier for users to see available plans, and that their sign-up process is quicker than the federal exchange.
But consumer advocates warn that Web brokers' presentation of insurance plan information may be influenced by their commission deals with those companies.
"For some plans you'll see the premiums, the benefits, the cost sharing - for other plans you'll see a name. That can really influence which plan a consumer might pick," said Ms. McAndrew, who added, "I always recommend that people go to the official marketplace website."
Broad Skepticism on Health Care Law
Enrollment Numbers Rise After Website Improves
Programmers Find New Way to Navigate Health Plans
Awareness Grows of Online Insurance Exchanges, and Their Problems, Survey Finds
Readers Ask About Subsidies and Other Health Care Law Provisions
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December 7, 2016 Wednesday
Late Edition - Final
Reproductive Rights in the Trump Era
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; WHAT'S AT STAKE; Pg. 28
LENGTH: 589 words
During his presidential campaign, Donald Trump sent mixed messages about his position on reproductive rights. Whatever his personal opinion may be, his appointees and their actions could put reproductive health care out of reach for millions of women, especially those living in poverty.
Mr. Trump has promised to appoint a Supreme Court justice who opposes Roe v. Wade, but overturning that decision would be a long process, probably requiring two new justices. Even without that change, there are many potent ways to restrict reproductive rights -- including not defending them against legal attack.
The Obama administration has waged long battles against such attacks. The Justice Department supported abortion providers in their successful challenge against unconstitutional abortion restrictions in the 2016 Supreme Court case Whole Woman's Health v. Hellerstedt. It defended the provision of the Affordable Care Act that requires insurers to cover birth control without a co-pay. It enforces the Freedom of Access to Clinic Entrances Act, which protects abortion providers and patients from violence and intimidation. After several states attempted to bar Planned Parenthood from receiving Medicaid reimbursements, the administration warned them that such measures could violate federal law. And the Department of Health and Human Services has proposed a rule that would bar states from cutting off federal family-planning funds to any provider for ideological reasons.
If Jeff Sessions, who opposes abortion, is confirmed as attorney general, the Justice Department is unlikely to defend reproductive rights. While the fate of the Affordable Care Act rests with Congress, the Justice Department could stop fighting lawsuits challenging the contraceptive coverage requirement. Under Mr. Sessions, it could stop enforcing the FACE Act, leaving abortion providers with little recourse if anti-abortion extremists threaten patients or doctors or obstruct clinic entrances.
Vice President-elect Mike Pence, when he was a congressman, tried to prevent any federal money from going to Planned Parenthood. The Trump administration, under Mr. Pence's guidance, could stop enforcing the Medicaid reimbursement law that prohibits states from discriminating against Planned Parenthood. And Tom Price, Mr. Trump's pick for secretary of health and human services and an unwavering opponent of the Affordable Care Act, could as head of that department rescind the contraceptive coverage requirement. Such federal actions may well embolden some Republican-controlled state governments to further restrict reproductive rights.
While the picture is bleak, there are ways states can ameliorate the harm. State legislatures can require that insurers cover birth control without a co-pay; four states already have such a requirement. States can protect family planning by increasing their support for these programs. The Montana Legislature did so last year with a bipartisan bill that moved federal family-planning funds into an account controlled by the state health department, making it harder for future legislators to cut them. And states can pass their own clinic safety laws to protect women and abortion providers.
Recent years have seen real progress in reproductive health, from lower rates of teenage pregnancy to more effective contraceptive use. Those are gains for Americans to build upon, not undo.
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July 10, 2012 Tuesday
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Good News for Mental Illness in Health Law
BYLINE: By RICHARD A. FRIEDMAN, M.D..
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.
SECTION: Section D; Column 0; Science Desk; MIND; Pg. 6
LENGTH: 813 words
Americans with mental illness had good reason to celebrate when the Supreme Court upheld President Obama's Affordable Care Act. The law promises to give them something they have never had before: near-universal health insurance, not just for their medical problems but for psychiatric disorders as well.
Until now, people with mental illness and substance disorders have faced stingy annual and lifetime caps on coverage, higher deductibles or simply no coverage at all.
This was supposed to be fixed in part by the Mental Health Parity and Addiction Equity Act of 2008, which mandated that psychiatric illness be covered just the same as other medical illnesses. But the law applied only to larger employers (50 or more workers) that offered a health plan with benefits for mental health and substance abuse. Since it did not mandate universal psychiatric benefits, it had a limited effect on the disparity between the treatment of psychiatric and nonpsychiatric medical diseases.
Now comes the Affordable Care Act combining parity with the individual mandate for health insurance. As Dr. Dilip V. Jeste, president of the American Psychiatric Association, told me, ''This law has the potential to change the course of life for psychiatric patients for the better, and in that sense it is both humane and right.''
To get a sense of the magnitude of the potential benefit, consider that about half of Americans will experience a major psychiatric or substance disorder at some point, according to an authoritative 2005 survey. Yet because of the stigma surrounding mental illness, poor access to care and inadequate insurance coverage, only a fraction of those with mental illness receive treatment.
For example, surveys show that only about 50 percent of Americans with a mood disorder had psychiatric treatment in the past year -- leaving the rest at high risk of suicide, to say nothing of the high cost to society in absenteeism and lost productivity. The World Health Organization ranks major depression as the world's leading cause of disability.
One of the health care act's pillars is to forbid the exclusion of people with pre-existing illness from medical coverage. By definition, a vast majority of adult Americans with a mental illness have a pre-existing disorder. Half of all serious psychiatric illnesses -- including major depression, anxiety disorders and substance abuse -- start by 14 years of age, and three-fourths are present by 25, according to the National Comorbidity Survey. These people have specifically been denied medical coverage by most commercial insurance companies -- until now.
From an epidemiologic and public health perspective, the provision that young people can remain on their parents' insurance until they turn 26 is a no-brainer: By this age, the bulk of psychiatric illness has already developed, and there is solid evidence that we can positively change the course of psychiatric illness by early treatment.
Mental disorders are chronic lifelong diseases, characterized by remission and relapse for those who respond to treatment, or persistent symptoms for those who do not. In schizophrenia, for example, relapse is common, even with the best treatment. It makes no sense to tell someone with this condition that his lifetime mental health benefit is just 60 days of inpatient hospitalization.
Psychiatric illness is treatable, but it is rarely curable; it may remit for a while, but it doesn't go away. That is why the current limits on treatment are as irrational as they are cruel -- the discriminatory hallmark of commercial medical insurance.
No more. The Affordable Care Act treats psychiatric illness like any other and removes obstacles to fair and rational treatment.
Older people with mental illness will also benefit, because the law will eventually fill in the notorious gap in Medicare drug coverage known as the ''doughnut hole.'' The law will immediately require drug companies to give a 50 percent discount on brand-name drugs and then gradually provide subsidies until the gap closes in 2020.
On the other hand, poor people with mental illness still have cause for concern. The new law would have expanded Medicaid to insure 17 million more Americans, but the Supreme Court ruled that states could decline to accept this expansion without losing their existing Medicaid funds. In states that opt out of the Medicaid expansion, poor people with mental illness may find themselves in a terrible predicament: They earn too much to qualify for Medicaid, yet not enough to get the federal subsidy to pay for insurance.
But on the whole, the Affordable Care Act is reason to cheer. Americans with mental illness finally have the prize that has eluded patients and clinicians for decades: the recognition that psychiatric illness should be on a par with all other medical disorders, and the near-universal mandate to make that happen.
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June 3, 2015 Wednesday
Late Edition - Final
13% Left Health Care Rolls, U.S. Finds
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 776 words
WASHINGTON -- About 13 percent of people who signed up for health insurance coverage in 2015 under the Affordable Care Act have fallen off the rolls, many because they failed to pay their share of premiums, the Obama administration said Tuesday.
The administration announced in March that 11.7 million people had signed up for coverage through federal and state marketplaces. On Tuesday, federal officials disclosed that enrollment stood at 10.2 million as of March 31.
Sylvia Mathews Burwell, the secretary of health and human services, issued the new enrollment report and highlighted data indicating that 6.4 million people were receiving federal subsidies to buy insurance in states where the marketplace, or exchange, was run by the federal government.
Those federal subsidies could be halted if the Supreme Court rules in favor of critics of the Affordable Care Act, who contend that the law authorized subsidies only in states that established their own exchanges. A ruling is expected in the next four weeks.
Nationwide, the administration said, the federal government is paying insurance subsidies in the form of tax credits to 8.7 million people, including 2.3 million in states that run their own exchanges. The average tax credit for those who qualified for financial assistance was $272 a month, the administration said.
The insurance marketplaces got off to a rocky start in October 2013, and President Obama paid a hefty political price as millions of consumers were frustrated trying to buy insurance. But the administration recovered, after making urgent repairs to HealthCare.gov, and by May 2014 the White House was celebrating the fact that eight million people had signed up for insurance in the first open enrollment period.
Federal officials on Tuesday disclosed that enrollment was substantially lower at the end of the year. About 6.3 million consumers were enrolled in health coverage through the marketplaces and had paid their premiums as of Dec. 31, 2014, they said.
But Ms. Burwell said there had been growth in enrollment since then. ''The health insurance marketplaces are working,'' she said Tuesday. ''We've seen a historic reduction in the uninsured, and consumers are finding the coverage they need at a price they can afford.''
In November 2014, less than a week before the marketplaces reopened for the 2015 enrollment period, Ms. Burwell offered a surprisingly modest estimate of the number of people who would sign up for insurance. She set a goal of having 9.1 million people on the rolls, with premiums paid, at the end of December 2015. Administration officials said Tuesday that they were on track to meet or surpass that goal.
Administration officials said they were confident that they would prevail in the pending Supreme Court case, King v. Burwell, and Ms. Burwell says she has not made contingency plans to deal with any disruption of subsidy payments. But the officials appeared to be eager to send a message -- to the public and the court -- about the hardship that could result from a ruling against the administration.
In its report Tuesday, the administration listed 11 states where more than 90 percent of consumers insured through the marketplace were receiving subsidies. Mississippi had the highest share, at 94.5 percent, followed in order by Florida, North Carolina, Wyoming, Louisiana, Arkansas, Georgia, Alabama, Wisconsin, Alaska and South Carolina.
Without subsidies, many people would be unable to afford insurance.
Of the 10.2 million people who were enrolled at the end of March, the administration said, 68 percent had selected midlevel ''silver plans,'' and 21 percent were in bronze plans.
While many people lost marketplace coverage because they failed to pay their share of premiums, some could have fallen off the rolls for other reasons -- if, for example, they obtained insurance through their employers or became eligible for Medicare or Medicaid.
The government also ended coverage for some people because they could not establish their citizenship or immigration status to the satisfaction of federal officials.
On March 31, the government terminated coverage through federal marketplaces for 117,000 consumers who could not document their citizenship or immigration status. For similar reasons, the government ended coverage for 109,000 people in 2014.
In addition, the government reduced, increased or eliminated subsidies for people whose income was different from what they had initially projected. Because of these ''income inconsistencies,'' the government said, it altered the subsidy level for 223,000 households this year and 97,000 households last year.
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GRAPHIC: GRAPHICS: New Estimates for Health Care Enrollment: Though 11.7 million people selected a health insurance plan in federal or state marketplaces through February, just 10.2 million completed enrollment and paid their first premiums, up from 6.3 million in 2014. (Source: Department of Health and Human Services)
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December 3, 2016 Saturday
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U.S. Health Spending in 2015 Averaged Nearly $10,000 Per Person
BYLINE: By ROBERT PEAR
SECTION: Section ; Column 0; Washington; Pg.
LENGTH: 732 words
WASHINGTON -- Total spending on health care in the United States increased last year at the fastest rate since the 2008 recession, reaching $3.2 trillion, or an average of nearly $10,000 a person, the Department of Health and Human Services reported on Friday.
The growth coincided with continuing increases in the number of Americans with insurance coverage, through private health plans or Medicaid.
Federal spending on health care has increased by 21 percent over the past two years, as millions of Americans gained coverage through the Affordable Care Act, the department said in its annual report on health spending.
The increase in federal spending was driven mainly by the expansion of Medicaid eligibility and enrollment, according to the report, published online in the journal Health Affairs.
Under the Affordable Care Act, the federal government has been paying the full cost of Medicaid coverage for newly eligible beneficiaries. Thirty-one states have chosen to expand eligibility.
Over all, the government said, health spending accounted for 17.8 percent of the nation's economy in 2015, up from 17.4 percent in 2014.
Total health spending rose 5.8 percent last year, and spending per person increased 5 percent. The Obama administration said this growth was ''below the rates of most years prior to passage of the Affordable Care Act.''
Anne B. Martin, an economist who was the principal author of the report, said the federal government became the largest source of health spending last year, accounting for 29 percent of the total -- more than households, private businesses or state and local governments. That stems not only from rising coverage through the health law but also an aging population, which is expanding Medicare.
The health law was always expected to fuel an increase in health spending, but the law has cost less than originally projected by the Congressional Budget Office, in part because the number of people signing up for subsidized coverage through online insurance exchanges was lower than expected.
Growth in total national health spending was exceptionally low for five years, from 2009 through 2013, in part because of lingering effects of the recession, officials said. The White House also asserted that the health law had slowed health spending, by cutting the growth of Medicare payments to many health care providers and by encouraging them to become more efficient.
''Over the last 55 years, the largest increases in health spending's share of the economy have typically occurred around periods of economic recession,'' Ms. Martin said. ''The 2014 and 2015 increases occurred more than five years after the last recession ended. But they coincided with 9.7 million individuals gaining private health insurance coverage and 10.3 million more people enrolling in Medicaid.''
Rapid increases in retail spending on prescription drugs also contributed to the growth of national health spending, officials said.
The report noted ''strong growth in new specialty medications such as those used to treat hepatitis C, cancer, autoimmune diseases and multiple sclerosis, as well as in more traditional brand-name medications such as those used to treat diabetes.''
In 2015, the report said, prices for existing brand-name drugs increased at a double-digit rate for the fourth consecutive year. An increase in the number of new drugs approved for use was also a factor.
''In 2015,'' the government said, ''45 new drugs were approved, more than in any one year over the past decade.''
Retail sending on prescription drugs grew 9 percent last year -- more than any other category of health care goods and services -- and reached $324.6 billion, representing 10 percent of all health spending, the government said.
Those figures understate drug spending, officials said, because they generally do not include spending on drugs administered in doctor's offices, hospitals and nursing homes.
In the past two years, the report said, 20 million people either gained private health insurance coverage or enrolled in Medicaid, primarily as a result of the Affordable Care Act. The share of the population with health coverage increased to 90.9 percent in 2015, from 86 percent in 2013, before the law's major coverage provisions took effect.
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URL: http://www.nytimes.com/2016/12/02/us/politics/us-health-care-spending.html
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November 11, 2014 Tuesday
Late Edition - Final
Estimate of Health Coverage Enrollment Leaves Room to Grow
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 18
LENGTH: 877 words
WASHINGTON -- The Obama administration on Monday offered a surprisingly modest estimate of the number of people who would sign up for health insurance in the second round of open enrollment, which begins on Saturday.
Sylvia Mathews Burwell, the secretary of health and human services, said she was working on the assumption that a total of 9.1 million people would have such coverage at the end of next year.
By contrast, the Congressional Budget Office had estimated that 13 million people would be enrolled next year, with the total rising to 24 million in 2016. In the past, the White House has used the budget office numbers as a benchmark for success under the Affordable Care Act.
The new estimate appeared to be part of an effort by federal officials to lower public expectations, so the goal would be easier to meet and to surpass. In addition, the new number could indicate that administration officials believe it will be difficult to find and enroll many of the uninsured while retaining those who signed up in the last year.
''The number we are going to aim for this year is 9.1 million,'' Ms. Burwell said on Monday during remarks at the Center for American Progress, a liberal research and advocacy group.
Ms. Burwell's estimate was at the lower end of the range suggested by health policy experts in her department. In a report issued earlier Monday, the experts estimated that, at the end of next year, 9 million to 9.9 million people would have coverage purchased through insurance exchanges, or marketplaces.
Representative Marsha Blackburn, Republican of Tennessee, said the administration was ''trying to manage expectations and rewrite its definition of success ahead of the second open-enrollment period.'' Administration officials said they were just being realistic, in the light of experience with other health programs.
President Obama announced in April that eight million people had signed up for health insurance under the Affordable Care Act. Officials said Monday that enrollment had declined to 7.1 million after some people failed to pay their share of premiums and others were found to be ineligible because of unresolved questions about their citizenship or immigration status.
The Department of Health and Human Services estimated that enrollment, including renewals and new customers, would reach 10 million to 11 million by the end of the three-month sign-up period, which closes on Feb. 15.
However, if Ms. Burwell is right, the number would shrink to 9.1 million people at the end of next year. That would still be a 28 percent increase over the number believed to have marketplace coverage today.
Ms. Burwell's estimate came as a surprise to insurance counselors, agents and brokers working with the Obama administration.
Anne Filipic, the president of Enroll America, a nonprofit group trying to expand coverage, said the goal of 9.1 million ''seems reasonable.'' She praised the administration for taking what she described as ''a pragmatic, analytic approach'' to setting a numeric goal.
Federal health officials said they had ended coverage for 112,000 people who could not demonstrate that they were United States citizens or legal immigrants entitled to insurance under the health care law.
In addition, they said, 120,000 households will lose some or all of the insurance subsidies they have been receiving because they could not adequately document their income. These households will face higher premiums.
In making their estimates, federal health officials said, they assumed that 83 percent of the people with marketplace coverage -- 5.9 million of the 7.1 million people in ''qualified health plans'' -- would renew their coverage.
The intense political debate swirling around the Affordable Care Act does not make the job of enrolling people any easier, officials said.
Republicans like Tom Cotton in Arkansas and Joni Ernst in Iowa won Senate races in which they emphasized opposition to the health care law, as did successful Republican House candidates like Mia Love in Utah and Ryan Zinke in Montana.
Senator John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, said that people were skeptical of the law and ''aren't signing up because they realize it's not a good deal for them.''
The Supreme Court said on Friday that it would consider a case challenging subsidies paid to more than four million people who obtained insurance through the federal marketplace.
Ms. Burwell said Monday that she did not see the legal challenge as a serious threat to the Affordable Care Act. ''As we go into open enrollment,'' she said, ''nothing has changed.''
Federal health officials said they believed that marketplace enrollment would grow more slowly than projected by the Congressional Budget Office, which sees the total holding steady at 25 million from 2017 to 2024.
Administration officials noted that uninsured people could also get coverage by enrolling in Medicaid or by finding jobs with health benefits.
In a brief analysis of coverage trends, the Department of Health and Human Services said Monday that ''most of the new marketplace enrollment for 2015 is likely to come from the ranks of the uninsured,'' rather than from people who previously bought insurance on their own outside the exchanges.
URL: http://www.nytimes.com/2014/11/11/us/us-gives-modest-forecast-for-enrollments-under-health-law.html
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GRAPHIC: PHOTO: Sylvia Mathews Burwell, the secretary of health and human services, estimated on Monday that 9.1 million people would sign up for insurance under the Affordable Care Act by the end of 2015. (PHOTOGRAPH BY CHIP SOMODEVILLA/GETTY IMAGES)
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The New York Times
April 3, 2014 Thursday
Late Edition - Final
Measuring the Success of Health Reform
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 518 words
More than seven million people have signed up for insurance on the new federal and state health exchanges, President Obama said this week. Millions more could be added to that total once insurers tally up the people who bought policies directly from them and when those who tried to apply on balky websites are able to complete the process.
This is a remarkable turnaround that seemed unlikely after the health care exchanges operated by the federal government and by several states got off to a horrendous start in October and continued to suffer intermittent difficulties as late as Monday, the last official day for enrolling for coverage in 2014. The figures provide stark evidence of the pent-up demand for health insurance and the willingness of people to comply with a law that has been vilified by conservatives as a disaster for millions of Americans.
The House speaker, John Boehner, has pledged to keep trying to repeal the Affordable Care Act, which he claimed is wreaking havoc on American families and the economy. But President Obama surely got it right when he said, ''The debate over repealing this law is over. The Affordable Care Act is here to stay.'' The Congressional Budget Office projects that enrollment in the exchanges will grow to 22 million in 2016.
Still, there is a lot we don't know yet, like how many people who signed up will actually pay their first month's premium (perhaps 80 percent to 90 percent by some estimates), what percentage of the enrollees are young and healthy (important for stabilizing the risk pools), how many of them were previously uninsured or poorly insured, and how many will be unhappy with their costs or choice of doctors.
One big uncertainty is whether premiums, which rise every year to keep pace with rising medical costs, will increase more in 2015 with health reform than they would have without it. That will depend heavily on where a person lives and the local health insurance market, not on national enrollments and nationwide costs. Risk pools are set at the state level, and premiums are set for smaller geographic areas where competition and other local factors will play a big role.
The law has already provided new coverage to millions of poor people in states that are expanding their Medicaid programs with the help of very generous federal matching funds. And it has also helped millions by reducing drug costs for chronically ill Medicare beneficiaries; allowing young adults to remain on their parents' policies; and providing preventive care without cost-sharing.
The success of the Affordable Care Act will ultimately be measured by how much it reduces the number of uninsured, whether it improves the quality of care and lowers costs, and by its effects on employment and federal and state budgets. Some effects won't be known for years.
In the meanwhile, Republicans and conservative political action groups are planning to make the repeal of health reform a major campaign issue in the midterm elections. Democrats will need to remind voters that many millions are already benefiting and millions more will be helped in coming years.
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October 1, 2013 Tuesday
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Obama's Remarks on the Budget and Health Law
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Following is the of President Obama's remarks from the White House briefing room on Monday afternoon, as transcribed by Federal News Service:
MR. OBAMA: Good afternoon, everybody.
Of all the responsibilities the Constitution endows to Congress, two should be fairly simple: Pass a budget, and pay America's bills. But if the United States Congress does not fulfill its responsibility to pass a budget today, much of the United States government will be forced to shut down tomorrow. And I want to be very clear about what that shutdown would mean, what will remain open and what will not.
With regard to operations that will continue, if you're on Social Security, you will keep receiving your checks. If you're on Medicare, your doctor will still see you. Everyone's mail will still be delivered, and government operations related to national security or public safety will go on.
Our troops will continue to serve with skill, honor and courage. Air traffic controllers, prison guards, those who are with border control -- Border Patrol will remain on their posts, but their paychecks will be delayed until the government reopens.
NASA will shut down almost entirely, but Mission Control will remain open to support the astronauts serving on the space station.
I also want to be very clear about what would change. Office buildings would close. Paychecks would be delayed. Vital services that seniors and veterans, women and children, businesses and our economy depend on would be hamstrung. Business owners would see delays in raising capital, seeking infrastructure permits or rebuilding after Hurricane Sandy.
Veterans, who've sacrificed for their country, will find their support centers unstaffed.
Tourists will find every one of America's national parks and monuments, from Yosemite to the Smithsonian to the Statue of Liberty, immediately closed. And of course the communities and small business that rely on these national treasures for their livelihoods will be out of customers and out of luck.
And in keeping with the broad ramifications of a shutdown, I think it's important that everybody understands the federal government is America's largest employer. More than 2 million civilian workers and 1.4 million active duty military serve in all 50 states and all around the world.
In the event of a government shutdown, hundreds of thousands of these dedicated public servants who stay on the job will do so without pay. And several hundred thousand more will be immediately and indefinitely furloughed without pay. What, of course, will not be furloughed are the bills that they have to pay: their mortgages, their tuition payments, their car notes. These Americans are our neighbors. Their kids go to our schools. They worship where we do. They serve their country with pride. They are the customers of every business in this country. And they would be hurt greatly, and as a consequence all of us will be hurt greatly, should Congress choose to shut the people's government down.
So a shutdown will have a very real economic impact on real people, right away. Past -- past shutdowns have disrupted the economy significantly. This one would too. It would throw a wrench into the gears of our economy at a time when those gears have gained some traction.
Five years ago right now, our economy was in meltdown. Today our businesses have created 7 1/2 million new jobs over the past three and a half years. The housing market is healing and our deficits are falling fast.
The idea of putting the American people's hard-earned progress at risk is the height of irresponsibility, and it doesn't have to happen.
Let me repeat this. It does not have to happen.
All of this is entirely preventable if the House chooses to do what the Senate has already done, and that's the simple act of funding our government without making extraneous and controversial demands in the process, the same way other Congresses have for more than 200 years.
Unfortunately, right now House Republicans continue to tie funding of the government to ideological demands like limiting a woman's access to contraception or delaying the Affordable Care Act, all to save face after making some impossible promises to the extreme right wing of their party.
So let me be clear about this. An important part of the Affordable Care Act takes effect tomorrow, no matter what Congress decides to do today. The Affordable Care Act is moving forward. That funding is already in place. You can't shut it down. This is a law that passed both houses of Congress, a law that bears my signature, a law that the Supreme Court upheld as constitutional, a law that voters chose not to repeal last November -- a law that is already providing benefits to millions of Americans in the form of young people staying on their parents' plan 'till they're 26, seniors getting cheaper prescription drugs, making sure that insurance companies aren't imposing lifetime limits when you already have health insurance, providing rebates for consumers when insurance companies are spending too much money on overhead instead of health care. Those things are already happening.
Starting tomorrow, tens of millions of Americans will be able to visit healthcare.gov to shop for affordable health care coverage. So Americans who've lived for years in some cases with the fear that one illness could send them into bankruptcy, Americans who've been priced out of the market just because they've been sick once, they'll finally be able to afford coverage, quality coverage, many of them for the first time in their lives.
Some of them may be sick as we speak. And this is their best opportunity to get some security and some relief. Tens of thousands of Americans die every single year because they don't have access to affordable health care.
Despite this, Republicans have said that if we'd lock these Americans out of affordable health care for one more year, if we sacrifice the health care of millions of Americans, then they'll fund the government for a couple of more months. Does anybody truly believe that we won't have this fight again in a couple of more months? Even at Christmas?
So here's the bottom line. I'm always willing to work with anyone of either party to make sure the Affordable Care Act works better, to make sure our government works better. I am always willing to work with anyone to grow our economy faster or to create new jobs faster, to get our fiscal house in order for the long run. I've demonstrated this time and time again, oftentimes to the consternation of my own party.
But one faction of one party in one house of Congress in one branch of government doesn't get to shut down the entire government just to refight the results of an election. Keeping the people's government open is not a concession to meet. Keeping vital services running and hundreds of thousands of Americans on the job is not something you give to the other side. It's our basic responsibility. It's something that we're doing for our military and our businesses and our economy and all the hard-working people out there -- the person working for the Agricultural Department out in some rural community who's out there helping some farmers make sure that they're making some modest profit for all the hard work they're putting in.
They're the person working for HUD who's helping somebody buy a house for the first time. They're somebody in a VA office who's counseling one of our vets who's got PTSD.
That's who we're here to serve. That's why we're supposed to be carrying out these responsibilities. That's why we should be avoiding the kinds of constant brinksmanship. It's something that we do in the ordinary process of this extraordinary system of government that we have. You don't get to extract a ransom for doing your job, for doing what you're supposed to be doing anyway, or just because there's a law there that you don't like.
The American people sent us here to govern. They sent us here to make sure that we're doing everything we can to make their lives a little bit better -- to create new jobs, to restore economic security, to rebuild the prospects of upward mobility. That's what they expect. And they understand that there are differences between the parties, and we're going to be having some tough fights around those differences.
And I respect the fact that the other party is not supposed to agree with me a hundred percent of the time, just like I don't agree with them. But they do also expect that we don't bring the entire government to a halt or the entire economy to a halt just because of those differences. And that's what they deserve. They've worked too hard for too long to recover from previous crises just to have folks here in Washington manufacture yet another one that they have to dig themselves out of.
So Congress needs to keep our government open. It needs to pay our bills on time and never, ever threaten the full faith and credit of the United States of America. And time's running out. My hope and expectation is that in the 11th hour once again that Congress will choose to do the right thing and that the House of Representatives in particular will choose the right thing.
Thank you very much.
URL: http://www.nytimes.com/2013/10/01/us/politics/obamas-remarks-on-the-budget-and-health-law.html
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July 4, 2013 Thursday
Late Edition - Final
Letting Employers Off the Hook, for Now
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 24
LENGTH: 398 words
The Obama administration made a reasonable decision this week to give employers another year before they will be required to make available affordable insurance to their workers or pay a fine. Republicans are portraying the decision as evidence that the whole health care reform is headed for a train wreck, but it actually affects only a narrow slice of companies and workers. It should have no bearing on whether the core provisions of the Affordable Care Act -- notably the opening of health care exchanges and subsidized coverage for people on modest incomes -- take effect on Jan. 1, 2014, as scheduled.
A vast majority of workers will be unaffected by the delay, and some of those whose companies are given a one-year reprieve may well be better off buying subsidized insurance on their own.
The act requires employers with more than 50 full-time workers to offer affordable health insurance starting next year or face fines of $2,000 to $3,000 per employee -- the ''employer mandate.'' Actually, the majority of the millions of companies in the United States have fewer than 50 employees; they are not required to offer health insurance but many are eligible for federal subsidies if they wish to do so. Most companies with more than 50 employees already provide affordable insurance.
Of some 230,000 firms that had 50 or more workers last year, the Kaiser Family Foundation estimates that about 11,500 did not offer health insurance. They employed roughly 1.4 million workers, about 1.6 percent of the more than 89 million workers at those companies.
Those workers will not be left in the lurch. Most will be able to buy policies on the health care exchanges that will open on January 1, 2014. Those on modest incomes (less than $88,000 a year for a family of four) will be eligible for federal subsidies on a sliding income scale. Many workers could conceivably obtain better coverage that way than from a parsimonious employer who might offer a plan but refuse to help employees pay for it.
There is a downside to the delay. It provides Republican critics with ammunition to portray the heath care reforms as a failure and could encourage other companies to demand exemptions from rules they don't like. But a year's delay will allow both employers and the Internal Revenue Service to figure out how this mandate will work. It is more important to do this right than to do it quickly.
URL: http://www.nytimes.com/2013/07/04/opinion/letting-employers-off-the-hook-for-now.html
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October 27, 2014 Monday
Late Edition - Final
Feared Costs Kept Some States From Expanding Medicaid Programs
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; MEDICAID; Pg. 17
LENGTH: 724 words
The Affordable Care Act allows states to expand Medicaid to people not previously eligible, including some people above the poverty level -- but the United States Supreme Court in 2012 ruled that expansion was optional for states.
As a result, only 27 states and the District of Columbia have expanded, while Republican opposition in other states has blocked expansion.
In states without expanded Medicaid, a coverage gap exists for people who earn too much to receive Medicaid, but too little to receive federal subsidies to reduce insurance premiums. About half of the people who fall in that gap nationally live in Texas, Florida or Georgia.
Under pressure from hospitals that stand to gain federal funds from Medicaid expansion, Republican governors in several states are now moving toward expansion, some through so-called private option plans.
Architects of the Affordable Care Act saw the expansion of Medicaid, the government health care program for low-income people, as a crucial step toward President Obama's goal of reducing the number of uninsured. And in states that have expanded eligibility -- to include people with incomes up to 138 percent of the poverty level (up to $16,105 for an individual) -- Medicaid appears to be achieving that goal.
Since last October, federal officials say, 8.7 million people have been added to the Medicaid rolls, 7.5 million of them in the 27 states that have expanded Medicaid eligibility. That is comparable to the 7.3 million people who obtained private insurance through the exchanges in all 50 states and the District of Columbia.
''States that expanded Medicaid have seen a remarkable reduction in the number of uninsured, a drop of nearly 40 percent,'' said Stan Dorn, a health policy expert at the Urban Institute, a nonprofit research group. ''That compares with a reduction of less than 10 percent in states that have not expanded.''
Not all states have expanded Medicaid, because the Supreme Court ruled in 2012 that the expansion was optional. So governments in 23 states, most of them Republican-controlled, have blocked expansion, asserting that the cost could eventually become a state responsibility.
But proponents of expansion say that will not be the case: Under the Affordable Care Act, the federal government pays all costs for newly eligible Medicaid beneficiaries through 2016, and after that the federal share never goes below 90 percent. Under traditional Medicaid, states pay a higher share -- 26 percent to 50 percent.
The government does not know for sure how many of the people gaining coverage under the Affordable Care Act were previously insured or uninsured.
Supporters of Medicaid assert that nonexpansion states are passing up hundreds of millions of federal dollars that could help offset cuts in aid to hospitals that will occur under other provisions of the health care law.
Moreover, sizable numbers of residents in those states, including childless adults and the working poor, fall into a coverage gap: They make too much for traditional Medicaid and too little to qualify for subsidies in the insurance exchanges.
Researchers at the Urban Institute estimate that 6.3 million uninsured adults fall into that coverage gap, with about half living in three states: Texas (1.5 million), Florida (1 million) and Georgia (570,000). The group includes 1.6 million blacks, 1.3 million Latinos and 1.5 million people under the age of 25.
Opposition to the expansion of Medicaid appears to be softening in some states, partly because of pressure from hospitals. Nine states with Republican governors, including Michigan, Ohio and Pennsylvania, are expanding Medicaid. Republican governors in Indiana and Utah are negotiating with the Obama administration on possible expansion. And in Tennessee, the Republican governor is trying to find a way to expand Medicaid despite skepticism among Republican lawmakers.
With so many new people in the expanded program, another question has emerged: Are there enough doctors to serve them? Many urban and rural areas were already struggling with shortages of doctors willing to take Medicaid patients before the law took effect, experts say.
''Beneficiaries have reported serious problems obtaining the care they need, particularly specialty care,'' said Sarah Somers, who represents poor people as a lawyer at the National Health Law Program.
URL: http://www.nytimes.com/2014/10/27/us/how-has-the-expansion-of-medicaid-fared.html
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April 6, 2017 Thursday
Late Edition - Final
As Latest Health Plan Dies, Republicans Can't Agree on a Culprit
BYLINE: By JENNIFER STEINHAUER and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1118 words
WASHINGTON -- The new bill to repeal the Affordable Care Act is dead, killed off by House Republicans who never actually read the legislation -- because in fact, it never actually existed.
Conservative groups moved quickly on Wednesday to shift the blame for the failure of a seven-year promise to repeal the law onto some not-as-conservative Republicans, after a small but powerful group of hard-line House conservatives failed again to come to a meeting of the minds with the Trump administration over how best to repeal and replace President Barack Obama's signature achievement.
''The left wing among House Republicans doesn't want to compromise or keep their pledge to voters to repeal Obamacare,'' David McIntosh, the president of the Club for Growth, a conservative free-market advocacy group, said in a statement. ''They've rejected deals that would give Americans more choices for cheaper health insurance, and now they won't even allow states the chance to scale back Obamacare's costliest regulations.''
The accusation -- echoed by other conservatives -- represents a remarkable turnaround in the blame game. The group and its supporters have opposed much of the major legislation considered by Congress in recent years.
Last month, a House Republican bill to repeal the Affordable Care Act failed to get enough support to bring it to a vote. About 30 of the most conservative members of the House rejected the bill as preserving too much of the existing law, but as they pressed to dismantle ever more provisions, they pushed away more moderate House Republicans who were leery of leaving 24 million more Americans without health insurance.
The effort was left for dead, until Vice President Mike Pence and other Trump administration officials raced up to the Capitol this week to cobble together a new agreement with the most conservative Republicans, the House Freedom Caucus. The revived measure, stirring in its grave, was known informally on Capitol Hill as Zombie Trumpcare.
According to several members, Mr. Pence had proposed allowing states to obtain waivers from two provisions of the Affordable Care Act. One provision requires insurers to cover a standard minimum package of benefits, including maternity care and emergency services. The other generally requires insurers to charge the same price to people of the same age who live in the same geographic area.
By allowing insurers to increase the cost of premiums for sick people, the waivers would effectively gut the Affordable Care Act's most popular provision: mandated access to insurance for people with pre-existing medical conditions. But members of the House Freedom Caucus were pushing to allow states to compensate with ''high-risk pools,'' where sick people could buy subsidized policies. Many congressional Republicans and President Trump viewed that option as morally and politically toxic.
The proposals never made it into a bill, and members never gave the ideas a full unadulterated blessing. The entire exercise appeared to melt in the midday sun on Wednesday, as members prepared for their two-week recess, set to begin Thursday afternoon.
Conservative groups were quick to attack the more moderate members of the Republican conference, particularly a group of lawmakers known as the Tuesday Group, as the reason the plan failed.
''The Tuesday Group is opposed because they do not want to repeal Obamacare,'' said Michael A. Needham, the chief executive of Heritage Action for America, a conservative group that opposed the original House Republican bill but remained supportive of the Freedom Caucus's efforts. ''They do not believe in policy innovation from the states. They do not believe in the basic premises of the Republican Party.''
Representative Charlie Dent, Republican of Pennsylvania and a leader of the Tuesday Group, agreed that making the plan less palatable to governors -- who were major opponents of the plan -- and trimming benefits further were not helping to win his vote.
''What they were talking about was not going to get me to yes,'' he said, noting that the plan was untenable to many governors, Republican senators and the vast majority of health care groups and representatives even before efforts to make it more acceptable began. ''This is just another gratuitous attack from the self-designated chiefs of the purity police on an issue of great consequence,'' he said.
In fact, the entire effort never really had the scent of veracity. Any effort to appeal to the hard-right members of the House Freedom Caucus was always going to repel Republicans in swing districts, especially those won in November by Hillary Clinton.
The objections to the House outline went far beyond the most moderate corners of the conference, and included people like Representative Christopher H. Smith, Republican of New Jersey and one of the most active anti-abortion members of the House, and Representative Don Young, Republican of Alaska, who objected to the way his state, with particularly high health care costs, would have fared. ''The congressman isn't one to often label himself,'' said Matthew N. Shuckerow, a spokesman for Mr. Young. ''He is Alaska first.''
If the most conservative House Republicans were blaming moderates, the moderates, for their part, were just as critical of the conservatives.
''The Freedom Caucus continues to play Lucy with the football and keeps moving the goal posts,'' said Representative Chris Collins, Republican of New York and the first member of the House to endorse Mr. Trump. ''I believe they are less than genuine in trying to get to yes.'' The suggestion by Heritage Action and the Club for Growth that moderates were to blame was ''ridiculous on its face,'' Mr. Collins said.
In reality, there was probably never time to pass the measure. House Republicans have been operating under somewhat arcane budget rules to avoid a Democratic filibuster in the Senate. At some point, Republicans hope to adopt a new budget resolution for the fiscal year that begins in October. They plan to use that budget resolution to focus on tax cuts, not on health care.
As conservative members prepared to return to their districts for the two-week spring recess, they desperately wanted to be able to tell their base voters that they were still trying to do away with the Affordable Care Act.
''We are going home tomorrow without a deal,'' Mr. Collins said. ''The Freedom Caucus says they want to get to yes, but their actions don't show that. The irony is, the very things they campaigned against will now be locked in because of their stubbornness.''
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URL: http://www.nytimes.com/2017/04/05/us/politics/health-care-house-republicans.html
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June 24, 2015 Wednesday
Late Edition - Final
A Ruling Against Obama Would Damage, Not Erase, a Health Care Legacy
BYLINE: By MICHAEL D. SHEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 1319 words
WASHINGTON -- The night his administration's Affordable Care Act passed in 2010, President Obama described the victory the way he hopes historians will: as a ''stone firmly laid in the foundation of the American dream.''
But Mr. Obama's prospects for a legacy of expanding health care coverage in the United States for generations have rarely seemed as uncertain as they do today. The Supreme Court is expected to rule by the end of the month on a critical provision of the Affordable Care Act -- insurance subsidies for millions of Americans -- and even Mr. Obama's closest allies say a decision to invalidate the subsidies would mean years of logistical and political chaos.
''Will that have, in the history books, an impact on the president?'' said Kathleen Sebelius, who as secretary of health and human services led the fight in Congress to pass the health care law. ''I'm sure. I know Republicans like to focus on how this would be a great blow to the president. But for heaven's sake, they would have a mess on their hands.''
In the Supreme Court case, King v. Burwell, conservatives have challenged the federal government's right to subsidize premiums for people who signed up for insurance through a federally run health marketplace. If the government loses, more than 6.4 million of those policy holders could see their premiums triple, or worse. Insurance companies could abandon marketplaces across the country. Mr. Obama's attempt to engineer a private-sector solution to the country's health insurance crisis could all but collapse.
''It would be a huge, devastating blow to the country,'' said Tom Daschle, a former Democratic senator from South Dakota. ''It is cataclysmic, from an insurance perspective.''
Health care experts say the elimination of subsidies would collapse the individual health care marketplaces in dozens of states and largely mean the end of the requirement to buy insurance in those places. But other parts of Mr. Obama's law should survive, including the guarantee of coverage regardless of pre-existing conditions, an expansion of Medicaid, rules allowing young people to be covered by their parents' insurance until age 26 and requirements that new health plans cover certain preventive care.
Republicans, who control Congress, say they are aware that Americans may look to them for a solution, and could blame them if bickering and gridlock get in the way. But many say they are gleeful that the court may do with a single decision what Republican lawmakers could not accomplish in five years: Cripple one of Mr. Obama's signature achievements.
''This is the beginning of the end of the Affordable Care Act,'' Representative Paul Ryan of Wisconsin, the chairman of the House Ways and Means Committee, said in an interview.
Mr. Ryan said Republicans were preparing legislation that would protect policy holders from losing subsidies until 2017, when Mr. Obama would no longer be in office. At that point, Mr. Ryan said, Republican lawmakers would try to work with the new president to fully dismantle the health care law and replace it with a more conservative approach.
''The key is to get into 2017,'' Mr. Ryan said. ''That's why the court ruling is so devastating to him. It will expose this law, and make it certain that Congress will be rewriting this law fully once he's gone.''
The president's allies still hold out hope that the court will not undermine the president's health care law, noting that even some Republicans believe that Congress intended to allow the subsidies when it passed the legislation. Mr. Daschle said he put the odds of the court's allowing the subsidies to continue at about 50-50.
Mr. Daschle said Mr. Obama had helped bring about other long-term changes to the country's health care system that would endure even if the court struck down the subsidies. As an example, he said, hospitals are moving away from the fee-for-service model of payment that has helped drive up the cost of health care.
''There's an inexorable quality to all of this,'' Mr. Daschle said. ''With each week, each passing month, each year, it becomes an integral part of the health care system.''
Making the changes part of the fabric of the American health care system was the essence of the White House strategy in 2009 and 2010. Mr. Obama and his top aides, led by Rahm Emanuel, who was the White House chief of staff, pushed Congress to pass a health care overhaul quickly to capitalize on Democratic control of Capitol Hill. They also wanted Mr. Obama to have time to put into action whatever law passed.
Over time, they believed, the changes would burrow their way into public expectations of what government should provide, much as Medicare and Social Security, and, in the process, become a major influence on the way Mr. Obama is remembered.
''For millions of Americans, the Affordable Care Act is embedded and is a reality,'' said David Axelrod, who was a senior adviser to Mr. Obama when the health care law was debated in the first term. ''That's not something to be trifled with.''
Polling suggests that public opinion is split about the health care law. In the latest New York Times/CBS News poll, 47 percent of those surveyed said they approved of the law, while 44 percent said they disapproved.
Still, most Americans do not appear eager to see the law's most critical benefits overturned by the court. In the survey, 70 percent said they thought that the government should continue to provide financial assistance to buy health insurance. That percentage included nearly nine in 10 Democrats, three-quarters of independents and four in 10 Republicans. If the court rules against the government, nearly two-thirds of those surveyed said, Congress should pass a law to reinstate the subsidies.
Even so, a ruling against the government by the Supreme Court would mean years of uncertainty for the Affordable Care Act.
Mr. Obama would leave office in January 2017 without knowing whether millions of people would remain stuck in the ranks of the uninsured. After years of blocking Republican attempts to tinker with the health care law, he would depart knowing that it remained under attack by his opponents. But it would be up to the next president and Congress to decide whether, and how, to fix it or abandon it altogether.
For the president's closest allies, that prospect is galling.
Mr. Axelrod, the protector of Mr. Obama's political brand, said the president was not ''sitting there thinking about his legacy.''
''He's thinking about what's the best thing for the country,'' Mr. Axelrod said.
But he is also a veteran campaign operative who spent much of the previous decade trying to get Mr. Obama into the Oval Office. He said the history books would record the president's efforts to pass a health care law against tremendous opposition, and the effect that the law has already had on millions of Americans.
''The reality is that people's lives have been affected in a very positive way,'' Mr. Axelrod said. ''That's not a legacy that's going to be erased easily.''
Ms. Sebelius said she worried most about the people who have been able to afford health insurance for the first time because of the subsidies. Some of those people would have to stop treatment if they suddenly lost their insurance because of the court's decision.
''That, to me, is what would be so wrenching and heartbreaking,'' Ms. Sebelius said. ''There are people whose lives had changed forever for the better. I don't know what then happens to them.''
But Mr. Ryan, who vowed to unwind the Affordable Care Act when he was a vice-presidential candidate in 2012, predicted the court would rule against the law.
''I think they cut corners trying to get this bill into law,'' Mr. Ryan said. ''Those chickens are coming home to roost.'' If the court rules against Mr. Obama, he added, ''I think it's a huge blow to his efforts to create a legacy.''
URL: http://www.nytimes.com/2015/06/24/us/supreme-court-ruling-on-health-law-will-shape-obamas-legacy.html
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May 1, 2014 Thursday
Late Edition - Final
The Problem With Free Health Care
BYLINE: By H. GILBERT WELCH.
H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and an author of ''Overdiagnosed: Making People Sick in the Pursuit of Health.''
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTOR; Pg. 25
LENGTH: 857 words
HANOVER, N.H. -- NOW that it's clear that Obamacare is here to stay, its supporters should focus on making the program better. Fixes are not a sign of weakness. They are a sign of responsiveness and of good management. And the Affordable Care Act does have its flaws. Here's a big one: It favors screening over diagnosis.
While the distinction may seem arcane, it has real-world implications. Screening is what we offer to the well; it's the effort to find abnormalities in those who do not have signs or symptoms of disease. Because screening is considered part of preventive care under the Affordable Care Act, it is provided at no charge.
Diagnosis is what we offer to those who do have signs or symptoms of disease. Because diagnosis is not preventive care, it is subject to deductibles and co-payments.
In other words: A woman over 40 can have a free screening mammogram. But if she notices a breast lump and goes to her doctor to have it evaluated, she'll pay for a diagnostic mammogram. That could cost $300. So the woman at lower risk for cancer -- the one with no signs or symptoms of the disease -- has an incentive to be tested, while the woman at higher risk -- the one with the lump -- faces a disincentive.
Does that make any sense? No. But it could encourage women with breast lumps not to report their symptoms.
Just how crazy this is became apparent to me when a friend enrolled on the New Hampshire exchange. Melissa is a 50-something self-employed author. She chose to be screened for colon cancer using the test doctors are most certain lowers colon cancer mortality -- annual fecal occult blood testing.
Melissa's screening test was free under the Affordable Care Act. It was also positive -- she had blood in her stool, meaning she was at higher risk to actually have colon cancer. Everyone agreed about the next step: a diagnostic colonoscopy, to figure out where the blood was coming from. That's not free; it's real money, thousands of dollars. But had she chosen the colonoscopy as her first screening test, it would have been free.
Melissa contacted her insurer, and a representative suggested she ask her gastroenterologist to resubmit the colonoscopy claim as preventive. Pressure on doctors to recode diagnostic tests as screening tests is the inevitable result of this ''incentive mismatch'' between screening and diagnosis. But it's also fraud, and Melissa knew it was wrong.
The gastroenterologists already got one fix in the Affordable Care Act. At first, screening colonoscopy was free, but if the test found a polyp, it was correctly reclassified as a diagnostic procedure, and was subject to cost sharing. In February 2013, regulators fixed the problem, saying insurance companies must also make polyp removal during screening free, noting, ''polyp removal is an integral part of a colonoscopy.''
It's true: Subsequent interventions are an integral part of all screening. Were I a mammographer, I'd happily argue that additional mammographic views, ultrasounds, M.R.I.s and breast biopsies are all part of screening.
But if you notice a new breast lump, you pay.
I wish money wasn't such a powerful incentive in medical care. But the economists are right: Incentives matter. Right now they favor lower risk patients (those being screened) over higher risk ones (those with signs and symptoms).
They also encourage a feeding frenzy among providers to recategorize diagnostic testing as screening. Free screenings were seen as a way to get people through the door and ideally to find and address problems before they become more dangerous and expensive.
But in practice, it may not work this way. Some hospitals offer free screening knowing full well that the costs will be more than made up for by all the subsequent services required. More testing, false alarms and overdiagnosis are all part of screening. And if you make it free, patients are less likely to give proper consideration to these potential harms -- not to mention the potential for a lot of out-of-pocket costs down the line.
Here's the fix: Eliminate the incentive mismatch between screening and diagnosis. Treat them equally. Melissa would share in the cost of her fecal occult blood test. (But at around $10 to $20, it's still roughly one one-hundredth of the cost of a colonoscopy.)
We need people to consider medical care carefully, and that's what cost sharing is all about. Patients already share costs on what is arguably the most important preventive service, treatment for really high blood pressure, and for procedures as necessary as setting a broken leg. Why would we treat a much closer call -- screening -- any different?
But if you think the need for this fix is evidence that the Affordable Care Act should be repealed, think again. Melissa had a mammogram at age 29 because her doctor thought she felt a lump. It was just fibrous tissue, but as a result, insurance companies put a rider on her policy disqualifying her from coverage for breast cancer. That's right: Before the Affordable Care Act, if she developed the cancer that leads to the most deaths among nonsmoking women, she would not have been covered. No one wants to go back there.
URL: http://www.nytimes.com/2014/05/01/opinion/the-problem-with-free-health-care.html
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The New York Times
July 6, 2012 Friday
Late Edition - Final
No Letup in the Health-Law Debate
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 22
LENGTH: 874 words
To the Editor:
If the Obama administration does not clarify the details of the Affordable Care Act -- clearly, simply, graphically and chronologically, so that every American can understand them -- we risk losing the most important legislative achievement of President Obama's first term.
One key vulnerability of the legislation remains the continuing confusion about what it includes, what changes will occur when, and who is affected. As detractors' talk of repealing the legislation grows, there is no time to waste.
One pamphlet, with a simple visual summary and timeline, would eradicate confusion and reassure millions of Americans with the indisputable facts, once and for all.
To see the Affordable Care Act repealed -- or to deprive it of the broad support it deserves -- simply because its contents were never plainly illustrated for every American would be a terrible shame, and a potentially irreversible blow to the future of health care in this country.
MICHAEL BALDWIN New York, July 3, 2012
To the Editor:
Re ''Reluctance in Some States Over Medicaid Expansion'' (front page, June 30):
The now very real possibility that many states will reject the Medicaid expansion has costly implications for the nation's uninsured poor. Medicaid expansion is supposed to be our guarantor that millions of vulnerable patients won't be denied care for ability to pay.
Keeping patients uninsured increases total health care costs through their heavy reliance on acute episodic care (avoidable emergency room visits and hospital admissions). It also results in higher rates of missed diagnoses, preventable complications of disease, and, of course, poor quality of life.
Physicians and health care workers ought to make these ramifications clear to the public and to their state legislators. Only then will state leaders acknowledge the political costs in rejecting billions of federal dollars for the much needed expansion of public insurance.
AMIR MOHAREB Baltimore, July 1, 2012
The writer, a medical student, is a Maryland state leader of Doctors for America.
To the Editor:
In the wake of the Supreme Court decision establishing the constitutionality of the Affordable Care Act, many Republicans are focusing their opposition on states' rights. They argue that rather than a ''one size fits all'' national plan, each state should be able to choose a policy that suits its own conditions. Mitt Romney defends his having championed a similar law in Massachusetts when he was governor in similar terms.
Let's not forget an important reality: many states, even if their governors wanted to enact health care reform to provide insurance to 98 percent of the population, as Massachusetts did, cannot afford to do so. And not just because of the recent recession. Some states are much poorer than others. Moreover, those states also tend to have larger numbers of people without insurance and would need to spend more to provide coverage for them.
One result of a state-based health care reform plan, therefore, would be that some citizens would be denied coverage that similar residents of other states would have -- simply because of where they happened to live.
STEPHEN M. DAVIDSON Boston, July 2, 2012
The writer is a professor at the Boston University School of Management and the author of ''Still Broken: Understanding the U.S. Health Care System.''
To the Editor:
Richard A. Epstein, in ''A Confused Opinion'' (Op-Ed, June 29), bases his critique of Chief Justice John G. Roberts Jr.'s opinion on the alleged inseparability of federal taxation and federal regulation. But the federal government routinely taxes things that it chooses not to regulate directly by law, and that the Supreme Court could possibly deem unconstitutional to so regulate, such as cigarettes and alcohol. Using taxation to discourage potentially harmful activity, instead of passing laws to forbid it, is a firmly established practice in America.
Whether you want to call these payments penalties or taxes is ultimately meaningless.
ALEXANDER DILLON New York, June 30, 2012
To the Editor:
Although I agree with your editorial decrying the heedless politicization of the Supreme Court by right-wing justices (''The Radical Supreme Court,'' July 1), your statement that the justices are not ''articulating a new social consensus'' is highly debatable. The excerpts from the Supreme Court hearing on the Affordable Care Act and Chief Justice John G. Roberts Jr.'s majority opinion make abundantly clear that the conservative justices believe they are upholding a new social consensus of the primacy of the marketplace in just about all facets of society.
Their obstinate refusal to concede that health care is a necessity and not a mere commodity like broccoli can only be rationally explained by the fact that such an admission would shatter the glass menagerie of their ideology. This is pathetic at best and dishonorable at worst.
Yet, before judging the justices, we must also consider that this ideology is arguably the prevailing social consensus, demonstrated by the high ratings of right-wing news media and the 2010 election results. Those of us who differ with this ideology can argue its merits, but its current pervasiveness is undeniable.
LARRY DEBLINGER Monroe, N.Y., July 1, 2012
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February 15, 2013 Friday
Older Workers Could Benefit if Companies Drop Insurance
BYLINE: CATHERINE RAMPELL
SECTION: BUSINESS; economy
LENGTH: 395 words
HIGHLIGHT: If employers are no longer on the hook for the health insurance costs of their employees, older job candidates - who consume more health care - may start to look more attractive.
As I've written before, older workers, once unemployed, have an extraordinarily difficult time finding re-employment. But they may get one unexpected employment booster next year: the health insurance exchanges put in place by the Affordable Care Act.
That theory was just proposed to me by John Challenger, the chief executive of Challenger, Gray & Christmas, a global outplacement and executive coaching company. Here's how it would work.
Once individuals are able to buy insurance on exchanges, employers may be tempted to "get out of the health care business," as Mr. Challenger put it. In other words, they will dump their workers onto the individual market. For most workers, this is probably a less-than-desirable outcome. But for older workers, it might be a blessing.
One potential reason that older workers have so much trouble finding work, after all, is that employers do not want to be responsible for their health care. Health care spending rises steadily by age; in fact, the health care costs of an older person are around five times those of a young adult. If employers are no longer on the hook for those health care costs, that is one less negative to be held against older job candidates.
Of course, those older workers would still have to find their own insurance, but the Affordable Care Act forces younger people to subsidize older people on the exchanges. Under the law, a health insurance plan's oldest subscriber can be charged no more than three times as much as a plan's youngest subscriber (even though, as mentioned, the oldest subscriber's costs are probably closer to five times as much).
It's worth noting that the exchanges might increase demand for older workers, but could also reduce their supply.
If older people no longer need to be on someone's staff in order to afford health insurance, they could decide to drop out of the job market altogether, or at least decide to go into business for themselves. We have already seen this phenomenon among Medicare-eligible workers. A recent Rand study documented a spike in entrepreneurship at age 65, when people newly qualify for Medicare and so have less to risk if they leave their employers and start their own businesses.
Older, but Not Yet Retired
The Depreciation of Care at Home
Employment of Elderly: Supply or Demand?
Why Hasn't Employment of the Elderly Fallen?
The Incomes of Physicians
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March 23, 2017 Thursday
The New York Times on the Web
The A.M.A.'s Opposition to the Health Bill
SECTION: Section ; Column 0; Editorial Desk; LETTER; Pg.
LENGTH: 170 words
To the Editor:
Re ''Health Groups Unite to Oppose Republican Bill'' (front page, March 9):
Like most who genuinely care about access to health care in the United States, I, too, oppose the Republican plan to repeal and replace the Affordable Care Act, and I am happy to see the American Medical Association and other health groups agree.
But let's not forget that the A.M.A. has opposed every major effort to increase access to health care in the United States, going back to President Harry Truman's proposal for national health insurance in the 1940s, the passage of Medicare in the 1960s, and, more recently, including a public option in the Affordable Care Act (though it did support the act itself).
The A.M.A. is a guild that first and foremost supports the financial well-being of physicians and cannot be counted on to act in the best interests of public access to care.
JAY V. SOLNICK, DAVIS, CALIF.
The writer, a doctor, is a professor of medicine at the University of California, Davis School of Medicine.
URL: http://www.nytimes.com/2017/03/22/opinion/the-amas-opposition-to-the-health-bill.html
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September 29, 2015 Tuesday
Hillary Clinton to Propose Scrapping Health Law's 'Cadillac Tax'
BYLINE: MAGGIE HABERMAN
SECTION: US; politics
LENGTH: 309 words
HIGHLIGHT: Hillary Rodham Clinton will in the coming days speak out against the “Cadillac tax” on certain health care plans, a move that is part of a series of reforms she’s suggesting for the Affordable Care Act, according to a union official briefed on her plans.
Hillary Rodham Clinton will in the coming days speak out against the so-called Cadillac tax on certain health care plans, a move that is part of a series of reforms she's suggesting for the Affordable Care Act, according to a union official briefed on her plans.
Mrs. Clinton's campaign aides informed Randi Weingarten, the president of the American Federation of Teachers, of her intentions in the last few days, according to a senior official with the labor group. The union made an early endorsement of Mrs. Clinton in July.
Many of the union's members would be affected by the Cadillac tax, which imposes taxes on pricey employer-based coverage plans whose premiums exceed $10,200 a year for individuals and $27,500 for families. The tax is imposed on employers, who can avoid it by reducing benefits to their workers. Its purpose is to help rein in health care costs over all.
Mrs. Clinton had indicated concerns about the tax in a questionnaire she answered for the union this year ahead of the endorsement.
A campaign official confirmed Ms. Weingarten's account of Mrs. Clinton's plans, but declined to elaborate.
Still, Mrs. Clinton has devoted this week and next to focusing on making fixes to President Obama's signature health care law, which she has described as generally effective but in need of certain tweaks.
Mrs. Clinton's move could help draw support for her campaign from other unions that have been holding off making an endorsement, in part because of support among organized labor's rank-and-file for Senator Bernie Sanders, the independent from Vermont.
Those briefed on her plans said she will have a method of replacing the lost revenue in the Cadillac tax through other means.
Find out what you need to know about the 2016 presidential race today, and get politics news updates via Facebook, Twitter and the First Draft newsletter.
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October 16, 2015 Friday
Late Edition - Final
Little Growth Predicted on Health Exchanges
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 728 words
WASHINGTON -- In a surprisingly pessimistic forecast, the Obama administration predicted on Thursday that health insurance enrollment on the Affordable Care Act's public marketplaces will only inch up from current coverage levels by the end of 2016.
After an elaborate analysis of demographic data, Sylvia Mathews Burwell, the secretary of health and human services, said that 10 million people were expected to have marketplace coverage at the end of next year, up only about 100,000 from recent levels and millions short of earlier projections. She called that ''a strong and realistic goal.''
''We still have work to do to bring access to affordable, quality health insurance to all Americans,'' Ms. Burwell said. ''But we're getting closer to that goal.''
About 9.9 million people had coverage through the federal and state insurance exchanges at the end of June, and administration officials predict that the enrollment will decline to 9.1 million by the end of this year. Some people fall off the rolls because they fail to pay their share of premiums. Others may obtain employer-sponsored coverage through a new job.
The next open enrollment period for the insurance marketplaces begins Nov. 1 and continues until Jan. 31.
Because of gains in coverage in the last two years, Ms. Burwell said, there are fewer uninsured Americans, and ''they are a little harder to reach.''
In addition, she said, ''the remaining uninsured have a lot of concerns about whether they can afford coverage,'' even with the financial assistance available under the Affordable Care Act.
The Congressional Budget Office predicted in March that enrollment through the exchanges would reach 11 million this year and 21 million in 2016.
But administration officials said that estimate was based on assumptions that proved to be invalid. For example, they said, the budget office assumed that significant numbers of employers would drop coverage and send their workers into the insurance exchanges, but that has not happened.
Discussing plans for the coming enrollment campaign, Ms. Burwell said, ''Our target assumes that more than one out of every four of the eligible uninsured will select plans.''
The new enrollment goal could serve a political purpose for Democrats running for election in 2016. They can more easily defend the Affordable Care Act if they can show it is achieving a goal set by the government. For their part, Republicans on Thursday seized on evidence of difficulties to buttress their claim that the law has been an expensive failure.
Census Bureau reports, considered the most authoritative source of data, show that nearly nine million people gained health insurance last year, lowering the ranks of the uninsured to 10.4 percent of the population, down from 13.3 percent in 2013. The change reflected the expansion of Medicaid in many states, as well as the purchase of subsidized insurance through the exchanges.
Obama administration officials said their efforts to expand coverage this fall would focus on five areas with large numbers of uninsured people: Dallas, Houston, northern New Jersey, Chicago and Miami.
Ms. Burwell laid out a series of intricate calculations to arrive at the goal of having 10 million people enrolled through the exchanges at the end of 2016.
She estimates that 7.3 million to 8.8 million people who now have marketplace coverage will select plans or be automatically re-enrolled in 2016. She estimates that 2.8 million to 3.9 million uninsured people will select plans in the coming enrollment period. And she predicts that 900,000 to 1.5 million people who bought insurance outside the exchanges this year will switch to policies sold through the marketplaces in 2016.
Combining these projections, Ms. Burwell estimates that 11 million to 14.1 million people will select health plans from November through January. Of these, she said, 9.4 million to 11.4 million will pay their premiums and retain marketplace coverage next year.
''I believe in clear metrics and goals,'' Ms. Burwell said. ''So I have picked a point that we will manage for, and that point is 10 million people with effectuated enrollment at the end of 2016. That's nearly one million more than this year.''
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URL: http://www.nytimes.com/2015/10/16/us/politics/health-insurance-enrollment-expected-to-see-small-increase.html
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January 20, 2017 Friday 00:00 EST
Trump Issues Executive Order Scaling Back Parts of Obamacare
BYLINE: JULIE HIRSCHFELD DAVIS and ROBERT PEAR
SECTION: US; politics
LENGTH: 867 words
HIGHLIGHT: The one-page order, which the newly inaugurated president signed in a hastily arranged Oval Office ceremony, did not specify which aspects of the health care law it was targeting.
WASHINGTON - In his first executive order, President Trump on Friday directed government agencies to scale back as many aspects of the Affordable Care Act as possible, moving within hours of being sworn in to fulfill his pledge to eviscerate Barack Obama's signature health care law.
The one-page order, which Mr. Trump signed in a hastily arranged Oval Office ceremony shortly before departing for the inaugural balls, gave no specifics about which aspects of the law it was targeting. But its broad language gave federal agencies wide latitude to change, delay or waive provisions of the law that they deemed overly costly for insurers, drug makers, doctors, patients or states, suggesting that it could have wide-ranging impact, and essentially allowing the dismantling of the law to begin even before Congress moves to repeal it.
The order states what Mr. Trump made clear during his campaign: that it is his administration's policy to seek the "prompt repeal" of the law, which has come to be known as Obamacare. But he and Republicans on Capitol Hill have not yet devised a replacement, making such action unlikely in the immediate term.
"In the meantime," the order said, "pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act, and prepare to afford the states more flexibility and control to create a more free and open health care market."
The order has symbolic as well as substantive significance, allowing Mr. Trump to claim he acted immediately to do away with a health care law he has repeatedly called disastrous, even while it remains in place and he navigates the politically perilous process of repealing and replacing it.
Using the phrase "to the maximum extent permitted by law," the order directs federal agencies to move decisively to implement changes, including granting flexibility that insurers and states had long implored the Obama administration to provide.
It also instructs them to work to create a system that allows the sale of health insurance across state lines, which Republicans have long proposed as the centerpiece of an alternative to the law.
"This action demonstrates that President Trump is committed to fixing the damage caused by Obamacare as soon as possible," said Senator John Barrasso, Republican of Wyoming.
The order does not direct the Department of Health and Human Services to ease any particular aspect of the 2010 law, but it could result in a substantial weakening of one of its central features: the so-called "individual mandate" that requires most Americans to have health insurance or pay a tax penalty.
While the Obama administration allowed "hardship exemptions" to the mandate, the Trump administration could conceivably interpret the requirement in a more lenient way, so that more people would not be penalized.
Likewise, federal officials could be more receptive to state requests for waivers under Medicaid, the federal-state program that covers more than 70 million low-income people. A number of Republican governors and state legislators would like to charge higher premiums or co-payments than are now allowed. Some states want to provide a less generous, less expensive package of benefits, or require some able-bodied adults to engage in work activities as a condition of receiving Medicaid.
Still, while Mr. Trump's directive allows officials to take steps that increase costs for consumers, that result is not inevitable. Indeed, the order says officials should try to reduce costs and burdens on consumers.
Over the last six years, insurance company executives have bitterly complained that federal insurance regulations were extremely prescriptive and onerous. By relaxing some of those rules, the Trump administration could make the individual insurance market more attractive to insurers. And insurers might then be more willing to stay in or return to the public marketplaces established under the Affordable Care Act.
In the last year, a number of insurers have dropped out of those markets, leaving consumers with fewer health plans to choose from.
House Republican leaders recently asked governors for recommendations on health policy, and governors from both parties said the federal government should scale back its regulation of health insurance.
Gov. Bill Haslam of Tennessee, a Republican, said this month that federal officials should "reconsider the premise that health insurance public policy should be directed from Washington." He said that federal rules for setting insurance rates and defining "essential health benefits" should be more flexible.
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PHOTO: President Trump signing his first executive order on Friday, on the Affordable Care Act. Its broad language gave wide latitude to change, delay or waive provisions. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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February 27, 2014 Thursday
Late Edition - Final
Behind Rise in Small-Business Premiums
BYLINE: By ROBB MANDELBAUM
SECTION: Section B; Column 0; Business/Financial Desk; YOU'RE THE BOSS; Pg. 6
LENGTH: 901 words
A new report from the federal government that says more small employers will see premiums increase than fall under the Affordable Care Act appears to have put the Obama administration on the defensive once again. But the report is remarkable as much for what it reveals about the current state of the small-group market as for how it might look under Obamacare, as the law is commonly known.
The report was produced by the Centers for Medicare and Medicaid Services at the request of Congress, and it is largely an exercise in the theoretical. The Affordable Care Act outlaws premium discrimination based on a company's industry, the size of its group, or the health status and gender of its employees. The law also limits premium variation based on age, and the study assumes that when all these rules eventually take effect, all small companies and their workers will pay essentially the same rates.
Meanwhile, the agency estimates that today, under the current rules, two-thirds of small employers pay premiums that are below the average rate and one-third pay above-average premiums. Therefore, under an Affordable Care Act that is fully in place, two-thirds will see their premiums rise, and one-third will see premiums fall.
Of course, we have long known that some people would pay more for health insurance under Obamacare and some people would pay less. What is interesting is the skew: Why is it that two-thirds of employers, and employees, according to the study, have paid below-average premiums? Why isn't it closer to 50/50? The answer, according to the study, is that under the old system, companies that paid lower premiums because their employees posed smaller health risks were more likely to offer health insurance in the first place.
But according to Jonathan Gruber, a health economist at M.I.T. whose work was cited in the C.M.S. report, those companies' premiums were not as far below the average as the premiums of those businesses that insured older, less healthy employees were above the average. ''The most expensive firms are very expensive, while the cheaper ones aren't that much cheaper,'' Mr. Gruber said. ''So what that means is that while the cheaper firms will lose, they will lose by less than the most expensive firms gain. The 65/35 is still consistent with the overall roughly net zero result that the Congressional Budget Office, myself, and others have estimated.''
It is also possible that companies that have not provided health insurance because it was too expensive may now be offered rates lower than what they were quoted in the past. The report estimates 18 million people get insurance through the small-group market, though not all will be affected by the new premium rules one way or the other. But according to the most recent figures from the Census Bureau, about 31 million people work for businesses with fewer than 50 employees. That means the current market leaves about 42 percent of small-business employees uninsured, and some of those would most likely find small-group insurance more affordable under the new rules.
The report did not quantify how much premiums would rise or fall. And it acknowledged that Congress asked the agency to study only three of the law's provisions and that other aspects of the law could affect how premiums change. ''The impact could vary significantly depending on the mix of firms that decide to offer health insurance coverage,'' the study said. ''In reality, the employers' decisions to offer coverage will be based on far more factors than the three that are focused on in this report.''
Republicans in Congress took the opportunity presented by the report to attack the law. Representative Sam Graves, the Republican from Missouri who heads the House Small Business Committee, called it ''one more in a long line of broken promises from President Obama and Washington Democrats.''
Curiously, the Obama administration seemed restrained in its response, choosing not to address the new study directly. When asked for a comment, a spokeswoman for the Department of Health and Human Services, Joanne Peters, said only, ''Since the Affordable Care Act became law, health care costs have been growing at the slowest rates on record and premiums are growing at less than one-half the pace seen a decade ago. The law is making it easier for businesses to offer coverage, just like it did in Massachusetts when employer coverage increased after reform passed.''
Tom Daschle, the former Democratic majority leader in the Senate and President Obama's first nominee to lead the Department of Health and Human Services, bemoaned what he said was an increasingly one-sided debate. ''There are so many ways to look at this,'' said Mr. Daschle, who is now a senior policy adviser to the law firm DLA Piper, of the C.M.S. report. For one thing, he said, the tax credits available to very small businesses that offer insurance will ''change tremendously the way premiums are paid.''
He went on to question why the administration had not responded more forcefully. ''I think it's been a big mistake that we're not pushing back as hard as we can,'' he said. ''There's an old saying attributed to Winston Churchill: a rumor gets halfway around the world before the truth gets its shoes on. That has happened over and over again with the Affordable Care Act.''
This is a more complete version of the story than the one that appeared in print.
URL: http://boss.blogs.nytimes.com/2014/02/25/why-most-small-business-owners-will-see-premiums-rise-under-a-c-a/
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February 13, 2014 Thursday
Assessing Who Benefits from the Latest Rulings on the Employer Mandate
SECTION: BUSINESS; smallbusiness
LENGTH: 1292 words
HIGHLIGHT: While most business interests were opposed to any form of a mandate, many trade groups were generally pleased with the final regulations.
Seth Perretta is a benefits lawyer in Washington who has represented several trade groups while the Internal Revenue Service has been writing the rules governing the Affordable Care Act's employer mandate.
His first impression, an hour after the Treasury Department made the final regulations public Monday afternoon? "All of this looks quite pro-employer, to be honest, so far," said Mr. Perretta, a lawyer from the Washington firm Crowell & Moring, as he leafed through the 227-page document.
His second impression, on Tuesday afternoon? "I think it's still pro-employer. There were things employers asked for that were not reflected in these regulations, but I think they were very responsive where they felt that they could be."
Of course, most business interests were strongly opposed to any form of a mandate, backed by a penalty, to provide health insurance to any employees. But given the statutory language handed to the I.R.S. to interpret, many trade groups, including the National Retail Federation and the National Restaurant Association, were generally pleased with the final regulations.
The biggest concession was granted to the smallest companies affected by the employer mandate: businesses with between 50 and 99 employees will not have to pay any penalties until 2016, a two-year delay from the law's original requirement. There are caveats: to win the temporary exemption, a company cannot cut its workforce to get below the mandate threshold between now and the rest of this year. Nor can it meaningfully reduce the health benefits it offers employees between now and the end of 2015.
The Affordable Care Act deems any business with 50 or more employees a "large employer" for the purposes of the mandate. "Calling a 51-employee firm a large company makes sense to no one," said Neil Trautwein, vice president, employee benefits policy counsel for the National Retail Federation. The one-year delay, he said, is the Obama administration's way of acknowledging that the smaller end of large "is a particularly vulnerable cohort of companies.
Even companies that have to abide by the mandate in 2015 - that is, those with at least 100 employees - will get some leeway in that first year. The law requires that companies offer insurance to 95 percent of full-time employees in order to avoid paying a penalty, but that requirement will not take effect until 2016. Next year, a company can avoid the penalty simply by offering insurance to 70 percent of full-time employees. (Full-time employees, under the law, are those who work 30 hours a week.)
This relief, however, is not quite as generous as it might seem at first glance, because the employer mandate actually contains an additional penalty: companies are also penalized for offering insurance that does not meet new standards set by health law for quality and affordability. This second penalty applies for each employee not offered coverage who then buys individual insurance and claims a government subsidy. Practically speaking, people not offered insurance are the ones most likely to qualify for a subsidy, so even if the temporary rules help a company escape the first penalty, costs under the second penalty could add up.
J.D. Piro, a senior vice president in charge of the health law group at the benefits consulting company Aon Hewitt, said that it is unlikely that companies will use this temporary provision as a way to evade the mandate. Referring to the initial requirement to offer coverage to 95 percent of employees, he said, "nobody was looking at that 5-percent margin as a planning margin. Five percent was more of a margin of error." The relaxed 70-percent requirement provides "a much greater margin of error, but I don't think it's going to be long-term strategy."
Mr. Perretta said it would be most helpful to companies that employ independent contractors or workers hired through staffing companies that could be deemed employees by the I.R.S. "It takes pressure off of employers because they don't have to worry about the potential for misclassification," he said. "It's unlikely they have mischaracterized 30 percent of their full-time employees."
The agency appeared to leave much of the regulation it initially proposed back in December 2012 largely intact. For example, one issue confounding some employers is whether they must offer insurance to an employee whose hours vary around the 30-hour threshold. The final rules keep an approach, called the "look-back measurement method," which allows a company to average its employees hours over a period of at least three months in the prior year in order to determine whether they are entitled to coverage in the current year. And regulators retained provisions for allowing employers to estimate whether the insurance they offer is affordable, which the law based on the worker's household income.
The I.R.S. crafted both sets of rules in close collaboration with trade groups. "An employer can't know family income, so Congress misfired in writing that part of the law," said Mr. Trautwein. But the I.R.S. will allow employers to substitute other measures, like the worker's gross income, for household income, which, Mr. Trautwein said, "makes sense to us."
The first draft of the rules also included transition relief meant to ease the way for businesses to comply with the mandate in 2014, and the agency is extending many of those temporary rules through next year. For example, under the law a business determines whether the mandate applies to it by averaging all of its employees' hours over the previous 12 months into full-time equivalents. For 2015, however, businesses can average the hours of any six consecutive months, so a growing or shrinking business can find an advantage by selecting the measuring period.
And a business does not have to comply with the mandate until its insurance plan year begins, rather than on Jan. 1. "If you have an October 1 plan date, you get 10 months relief from the mandate," Mr. Perretta said.
Mr. Trautwein, of the retailers' group, praised the Obama administration for engaging in "three years of dialogue" with business interests. "These are smart people trying to do the right thing," he said. "This is an example of getting it right, or close to that. When the administration does well, you have to show your appreciation."
Such gratitude was not universal, however. Several trade groups criticized the I.R.S. rules as emblematic of the health law's broader failings. The International Franchise Association objected to the I.R.S.'s unwillingness to raise the threshold for employees who must be offered insurance from those who work 30 hours a week to those who work 40 hours. The National Association of Home Builders' chief executive, Jerry Howard, criticized the agency for not revisiting a requirement that all companies with a common owner be treated as a single entity for the purpose of the mandate. But both of these provisions were written directly into the law, and other observers said the I.R.S. had no choice but to follow Congress's direction on them.
Meanwhile, the National Association of Manufacturers complained that the further delay created a feeling that the law's requirements were not fixed. "At the end of the day, was there some acknowledgement of flexibility within the regulation they released yesterday? The answer would be yes," said Joe Trauger, the organization's vice president of human resources policy. "But what is it tomorrow?"
The Employer Mandate Has Been Delayed. Will It Be Rewritten?
It's the Affordable Care Act. But What Is Affordable?
In the Affordable Care Act, Some Children Left Behind
Could Employers Use Immigrants to Avoid the Health Mandate?
A Hotelier Corrects His Testimony on the Impact of the Affordable Care Act
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November 30, 2016 Wednesday 00:00 EST
Tom Price, a Radical Choice for Health Secretary;
Editorial
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 620 words
HIGHLIGHT: Donald Trump has picked a man intent on systematically weakening, if not destroying, the nation's health care safety net.
In picking Representative Tom Price, President-elect Donald Trump has chosen as his secretary of health and human services a man intent on systematically weakening, if not demolishing, the nation's health care safety net.
Mr. Price, a Republican from Georgia, is a fierce opponent of the Affordable Care Act, the 2010 health reform law, and beyond that, supports plans to slash Medicare and Medicaid, which cover tens of millions of elderly, disabled and low-income Americans. He is against a woman's right to choose and has backed legislation to strip Planned Parenthood of federal funding.
Mr. Trump and many Republicans have talked vaguely about plans to repeal the health reform law but suggest they might keep some popular parts of the law. Mr. Price makes no such noises. The detailed legislation he introduced most recently in 2015 would destroy the reform law and is a good indication of his philosophy in managing the nation's largest health programs: cut benefits and leave millions with no health care at all.
His bill would, among other things, roll back the federally financed expansion of Medicaid in 31 states and the District of Columbia, taking coverage away from 14 million poor people. It would severely cut federal subsidies that help individuals and families buy policies on government-run health exchanges. The reduced subsidies would make it hard, if not impossible, for millions to afford the coverage they have gotten since the Affordable Care Act went into effect. And the bill would no longer require insurers to cover addiction treatment, birth control, maternity care, prescription drugs and other essential medical services.
As for coverage of pre-existing medical conditions - a key element of the current law, requiring insurers to sell plans to those with health problems - Mr. Price's bill has that protection only for those who maintained continuous health coverage with any insurer for the previous 18 months. This means that insurers would not be required to sell an affordable plan to anyone who did not have coverage for, say, a month while he or she was between jobs.
Beyond his commitment to tearing apart the health care law, Mr. Price, who leads the House Budget Committee, published a budget proposal last year that would convert Medicaid into a block grant to state governments. This would reduce federal spending on the program by 34 percent by 2025, according to the Center on Budget and Policy Priorities. Such a cut would inevitably cause states to offer fewer benefits and reduce the number of people covered, far beyond the 14 million who would lose their coverage if Medicaid expansion is rolled back.
Mr. Price also supports big changes to Medicare that could hurt older Americans by increasing their health care costs. A plan backed by Mr. Price and the House speaker, Paul Ryan, would turn Medicare, which covers the cost of medical care for people over 65, into a program in which people would buy private insurance through what is known as premium support. The idea is to turn Medicare into a voucher program, designed to limit federal spending while forcing seniors to bear more of the cost. Given that most American families have little or no retirement savings, this would be disastrous. It also stands in stark contrast to Mr. Trump's campaign promise not to "cut" Medicare and Social Security.
It is impossible to know which parts of Mr. Price's agenda will become priorities for the new administration. But we do know that he will now have a very powerful perch from which to advocate his radical positions.
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DRAWING (DRAWING BY OLIVER MUNDAY)
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January 23, 2017 Monday
Late Edition - Final
Replacement for Health Law Would Convert Medicaid to Block Grants, Trump Aide Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 758 words
WASHINGTON -- President Trump's plan to replace the Affordable Care Act will propose giving each state a fixed amount of federal money in the form of a block grant to provide health care to low-income people on Medicaid, a top adviser to Mr. Trump said in an interview broadcast on Sunday.
The adviser, Kellyanne Conway, who is Mr. Trump's White House counselor, said that converting Medicaid to a block grant would ensure that ''those who are closest to the people in need will be administering'' the program.
A block grant would be a radical change. Since its creation in 1965, Medicaid has been an open-ended entitlement. If more people become eligible because of a recession, or if costs go up because of the use of expensive new medicines, states receive more federal money.
If Congress decides to create block grants for Medicaid, lawmakers will face thorny questions with huge political and financial implications: How much money will each state receive? How will the initial allotments be adjusted -- for population changes, for general inflation, for increases in medical prices, for the discovery of new drugs and treatments? Will the federal government require states to cover certain populations and services? Will states receive extra money if they have not expanded Medicaid eligibility under the Affordable Care Act, but decide to do so in the future?
Ms. Conway, speaking on the NBC program ''Sunday Today,'' said that with a block grant, ''you really cut out the fraud, waste and abuse, and you get the help directly'' to intended beneficiaries.
Medicaid covers more than 70 million people at a combined cost of more than $500 billion a year to the federal government and the states. More than 20 million people have gained coverage under the Affordable Care Act, more than half of them through Medicaid.
The new Congress has approved a budget that clears the way for speedy action to repeal the health care law, President Barack Obama's signature domestic achievement. And Mr. Trump has said Congress should take action to repeal and replace the law at the same time, putting pressure on lawmakers to agree on an alternative.
As a candidate, Mr. Trump said he wanted to ''maximize flexibility for states'' so they could ''design innovative Medicaid programs that will better serve their low-income citizens.'' On Friday, in his first executive order, he directed federal officials to use all their authority to ''provide greater flexibility to states'' on the health law.
As part of their ''Better Way'' agenda, House Republicans said in June that they would roll back the Affordable Care Act's expansion of Medicaid and give each state a set amount of money for each beneficiary or a lump sum of federal money for all of a state's Medicaid program -- ''a choice of either a per capita allotment or a block grant.''
Governors like the idea of having more control over Medicaid, but fear that block grants may be used as a vehicle for federal budget cuts.
''We are very concerned that a shift to block grants or per capita caps for Medicaid would remove flexibility from states as the result of reduced federal funding,'' Gov. Charlie Baker of Massachusetts, a Republican, said this month in a letter to congressional leaders. ''States would most likely make decisions based mainly on fiscal reasons rather than the health care needs of vulnerable populations.''
Gov. Robert Bentley of Alabama, a Republican, said that if a block grant reduced federal funds for the program, ''states should be given the ability to reduce Medicaid benefits or enrollment, to impose premiums'' or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways.
In Louisiana, Gov. John Bel Edwards, a Democrat, said he was troubled by the prospect of a block grant with deep cuts in federal funds. ''Under such a scenario,'' he said, ''flexibility would really mean flexibility to cut critical services for our most vulnerable populations, including poor children, people with disabilities and seniors in need of nursing home and home-based care.''
Gov. John W. Hickenlooper of Colorado, a Democrat, said that block grant proposals could shift costs to states and ''force us to make impossible choices in our Medicaid program.''
''We should not be forced to choose between providing hard-working older Coloradans with blood pressure medication or children with their insulin,'' Mr. Hickenlooper said.
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URL: http://www.nytimes.com/2017/01/22/us/politics/donald-trump-health-plan-medicaid.html
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April 9, 2014 Wednesday
The Power of Sebelius
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 835 words
HIGHLIGHT: Kathleen Sebelius’s decision on how to calculate premium adjustments for health insurance could add billions to the federal deficit, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
In setting the 2015 calendar parameters for health plans and employers, Kathleen Sebelius, the secretary of health and human services, quietly did some creative but questionable arithmetic that forced taxpayers to give still more help to businesses and people who buy health insurance.
The Affordable Care Act is designed to encourage people to enroll in a health insurance plan and to shop around for value for their medical dollars.
On the first point, the law says large employers will be charged a penalty for not providing coverage to their full-time employees (and thereby helping their employees get taxpayer-subsidized coverage). The amount of the penalty was set to be economically significant relative to the costs of coverage.
On the second point, people enrolled in health plans are asked to pay part of their medical expenses - "cost-sharing," as the law calls it. This is why the plans sold on healthcare.gov have high deductibles in comparison with traditional employer plans. The amount that plan participants are supposed to pay is supposed to be commensurate with the costs of medical care.
To achieve both of these goals, the law specifies that the cost-sharing rules and the employer penalty be indexed to health cost inflation. Specifically, the Affordable Care Act says that in each year after 2014, the employer penalty and cost-sharing parameters will exceed the value they have in 2014 by a percentage equal to the "premium adjustment percentage," which is "the percentage (if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the secretary no later than Oct. 1 of such preceding calendar year) exceeds such average per capita premium for 2013 (as determined by the secretary)." The "secretary" refers to the secretary of the Department of Health and Human Services, currently Ms. Sebelius.
The average per capita premium for health insurance coverage increased in 2013, especially in the individual market, because the Affordable Care Act required plans to provide more benefits. For example, the eHealth price index was about 40 percent greater during the first quarter of 2014 than it was for calendar year 2013 (see this chart, in which the dotted red line is the 2013 average). This is no surprise - more benefits mean higher premiums - and I presume that Congress understood this.
This is not to say that high-premium high-benefit plans are undesirable, just that, without subsidies, you get what you pay for, and pay for what you get.
But a political problem arises in that a premium increase that averages, say, 40 percent would require a 40 percent increase in the caps on what individuals with coverage can be asked to pay for their own medical expenses and increase the employer penalty by 40 percent (above what it would have been had it been enforced in 2014).
Among other things, the salary equivalent of the employer penalty next year, with a 40 percent premium adjustment percentage, would be almost $4,300 per employee per year.
To make matters (politically) worse, the increase in premiums from 2013 to 2014 is likely to be permanent, because the new rules on minimum benefits are permanent (as the law now stands). In other words, an increase in caps and penalties next year would be likely to last long into the future. The Department of Health and Human Services needed a way to measure the average premium for health insurance without acknowledging what is actually happening to health insurance premiums.
The department explains the two principles behind its solution. The first principle is to estimate premiums with its own projections, rather than averaging actual premiums observed in the marketplace. The second principle is to limit its use of data to market segments where "the premium trend is more stable."
Since only one year has passed since 2013, for now that means limiting the data used to market segments where the premium adjustments are sufficiently close to zero.
In particular, for now the premiums in the individual market will be ignored for the purposes of estimating changes in premiums. As a result, the secretary has declared that the premium adjustment percentage is but a fraction of 40 percent: 4.2 percent, when rounded off.
I am not saying that the premium adjustment percentage should have been 40, just that it should have been based on actual transactions in all of the market segments, and as a result significantly greater than 4.2.
Perhaps taxpayers of the future will remember March 11, 2014, as the day when one cabinet secretary added billions of dollars to the deficit.
The Midterm Grade for HealthCare.gov
Obamacare vs. Romneycare: The Labor Impact
Health Reform, the Reward to Work and Massachusetts
'Romneycare' and the 29ers
The Affordable Care Act's Multiple Taxes
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January 5, 2017 Thursday
Late Edition - Final
Senate G.O.P. Opens Fight Over Obama Health Law
BYLINE: By THOMAS KAPLAN and GLENN THRUSH; Robert Pear and Emmarie Huetteman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1134 words
WASHINGTON -- Congress opened for battle over the Affordable Care Act on Wednesday as Republicans pushed immediately forward to repeal the health care law and President Obama made a rare trip to Capitol Hill to defend it.
The bitterness that has long marked the fight intensified as Republicans seized the opportunity to make good on a central campaign promise to get rid of the law, a pledge reinforced on Wednesday by Vice President-elect Mike Pence, who met with House Republicans not far from where the president gathered with Democrats.
The Affordable Care Act, Mr. Obama's signature health care law, has created online insurance marketplaces, offered new protections to people seeking health insurance, and provided coverage to millions of people near the poverty line through expanded Medicaid. Health policy experts say that system could collapse if Republicans cut off funds for the expanded coverage and end penalties for people who go without health insurance.
''The American people voted decisively for a better future for health care in this country,'' Mr. Pence said, ''and we are determined to give them that.'' He said that President-elect Donald J. Trump would use his executive authority to help make the transition away from the health care law, but did not offer specifics.
Democrats vowed aggressive resistance, however, and said they would not participate in drawing up a replacement for the law after the swift efforts to unravel it. Senator Chuck Schumer of New York, the new Democratic leader, playing off Mr. Trump's campaign slogan, said repealing the law would ''make America sick again.''
Republicans are using a procedural approach that will allow them to repeal substantial parts of the health care law without Democrats' being able to mount a filibuster in the Senate.
By a vote of 51 to 48 on Wednesday, the Senate took the first step, agreeing to take up a budget resolution, or blueprint, that would clear the way for legislation repealing major provisions of the law. But even as Republicans spoke of moving quickly to repeal the law, it remained far less clear how and when they would go about replacing it.
Senate debate on the budget resolution is expected to continue for several days, and the House plans to take up the measure once the Senate has approved it.
As Republicans charged ahead, both sides seemed cognizant of the possible fallout from unwinding the law, which has become deeply enmeshed with America's health care system and has provided insurance for about 20 million people.
Mr. Trump weighed in with several Twitter posts. He advised that Republicans needed to ''be careful in that the Dems own the failed Obamacare disaster,'' and added, ''Don't let the Schumer clowns out of this web.''
Mr. Trump predicted that the health care law would ''fall of its own weight.''
Representative Chris Collins of New York, a Republican who is one of Mr. Trump's top supporters in Congress and is part of his transition team, said it was important to be sure that Democrats bear responsibility for the failings of the health care law. Republicans point out that premiums have risen and that consumers in many places have fewer choices of insurers.
''We have to make sure we keep reminding America, we are repealing it because it failed, we are repealing it because they all but demanded that we repeal it,'' Mr. Collins said. ''And that was a key piece of Donald Trump's campaign.''
But as Republicans expressed eagerness to repeal the law, they acknowledged that replacing it would take more time. It is also unclear how insurance companies will react during this period and whether they will continue to offer the marketplace plans that millions of people have come to rely on.
''There will naturally be a reasonable transition period,'' said Senator Ted Cruz, Republican of Texas. ''You can't adopt new reforms all at once.''
Senator John Cornyn of Texas, the No. 2 Senate Republican, noted that it had taken six years to get into ''the ditch we find ourselves in now.''
''When your truck or car is in a ditch, the first thing you need to do is get out of the ditch,'' Mr. Cornyn said. ''And sometimes that takes a lot of hard work.''
To that, Senator Debbie Stabenow, Democrat of Michigan, parried that when a car goes into a ditch, ''the first thing I don't do is dismantle the car.''
''That doesn't help me get anywhere in terms of transportation,'' she said.
Democrats signaled little interest in helping Republicans determine what to do after repealing major parts of the health care law.
Mr. Schumer predicted that in a year, Republicans would ''regret that they came out so fast out of the box.'' He said Democrats would consider working on a replacement only after Republicans presented their own plan.
''If you are repealing, show us what you'll replace it with first,'' Mr. Schumer said. ''Then we'll look at what you have and see what we can do.''
Later, Mr. Schumer said of Mr. Trump, ''It's his and their responsibility, plain and simple -- name calling isn't going to get anything done.'' He added, ''They really need to calm things down a little.''
Speaker Paul D. Ryan tried to offer assurance that no change in coverage would be abrupt.
''The point is, in 2017, we don't want people to be caught with nothing,'' he said. ''We want to make sure that there's an orderly transition so that the rug is not pulled out from under the families who are currently struggling under Obamacare while we bring relief.''
Mr. Obama huddled with congressional Democrats for about 90 minutes in what was billed by the White House as a strategy session to forge a unified Democratic response to the Republicans' rollback effort.
In reality, the session was essentially a going-away party for a man who passed his signature legislative accomplishment under long-extinct majorities in Congress and a ''pep rally'' for Affordable Care Act defenders, in the words of an attendee, Representative Hank Johnson, Democrat of Georgia.
The gathering, which could be Mr. Obama's last trip to the halls of Congress that have been the site of alternating triumph and defeat, had a two-weeks-before-graduation air, with numerous Democratic lawmakers, including Mr. Johnson, sneaking out to attend to business more pressing than hearing the president's words.
Mr. Obama, for his part, did not ask his allies to block all efforts to alter the law, but warned Democrats against ''rescuing'' Republicans by defecting on votes that would dismantle it.
The president provided an array of arguments for keeping the Affordable Care Act and offered a mild mea culpa for his shortcomings as a salesman over the years.
Senator Jeff Merkley, Democrat of Oregon, said, ''He acknowledged the failures in selling the law in its entirety to the American people.''
URL: http://www.nytimes.com/2017/01/04/us/politics/obama-democrats-affordable-care-act.html
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GRAPHIC: PHOTOS: Top, President Obama on Capitol Hill on Wednesday before meeting with Democrats. Above, Vice President-elect Mike Pence with Speaker Paul D. Ryan after a Republican caucus. (PHOTOGRAPHS BY AL DRAGO/THE NEW YORK TIMES
DOUG MILLS/THE NEW YORK TIMES) (A1)
The Capitol on Wednesday. Inside, the Republican-led Congress began taking steps to roll back the Affordable Care Act. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A12)
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December 2, 2016 Friday 00:00 EST
Seduced and Betrayed by Donald Trump;
Op-Ed Columnist
BYLINE: PAUL KRUGMAN
SECTION: OPINION
LENGTH: 829 words
HIGHLIGHT: The white working class is due for a rude awakening when the safety net is shredded.
Donald Trump won the Electoral College (though not the popular vote) on the strength of overwhelming support from working-class whites, who feel left behind by a changing economy and society. And they're about to get their reward - the same reward that, throughout Mr. Trump's career, has come to everyone who trusted his good intentions. Think Trump University.
Yes, the white working class is about to be betrayed.
The evidence of that coming betrayal is obvious in the choice of an array of pro-corporate, anti-labor figures for key positions. In particular, the most important story of the week - seriously, people, stop focusing on Trump Twitter - was the selection of Tom Price, an ardent opponent of Obamacare and advocate of Medicare privatization, as secretary of health and human services. This choice probably means that the Affordable Care Act is doomed - and Mr. Trump's most enthusiastic supporters will be among the biggest losers.
The first thing you need to understand here is that Republican talk of "repeal and replace" has always been a fraud. The G.O.P. has spent six years claiming that it will come up with a replacement for Obamacare any day now; the reason it hasn't delivered is that it can't.
Obamacare looks the way it does because it has to: You can't cover Americans with pre-existing conditions without requiring healthy people to sign up, and you can't do that without subsidies to make insurance affordable.
Any replacement will either look a lot like Obamacare, or take insurance away from millions who desperately need it.
What the choice of Mr. Price suggests is that the Trump administration is, in fact, ready to see millions lose insurance. And many of those losers will be Trump supporters.
You can see why by looking at Census data from 2013 to 2015, which show the impact of the full implementation of Obamacare. Over that period, the number of uninsured Americans dropped by 13 million; whites without a college degree, who voted Trump by around two to one, accounted for about eight million of that decline. So we're probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.
Why did they do it? They may not have realized that their coverage was at stake - over the course of the campaign, the news media barely covered policy at all. Or they may have believed Mr. Trump's assurances that he would replace Obamacare with something great.
Either way, they're about to receive a rude awakening, which will get even worse once Republicans push ahead with their plans to end Medicare as we know it, which seem to be on even though the president-elect had promised specifically that he would do no such thing.
And just in case you're wondering, no, Mr. Trump can't bring back the manufacturing jobs that have been lost over the past few decades. Those jobs were lost mainly to technological change, not imports, and they aren't coming back.
There will be nothing to offset the harm workers suffer when Republicans rip up the safety net.
Will there be a political backlash, a surge of buyer's remorse? Maybe. Certainly Democrats will be well advised to hammer Mr. Trump's betrayal of the working class nonstop. But we do need to consider the tactics that he will use to obscure the scope of his betrayal.
One tactic, which we've already seen with this week's ostentatious announcement of a deal to keep some Carrier jobs in America, will be to distract the nation with bright, shiny, trivial objects. True, this tactic will work only if news coverage is both gullible and innumerate.
No, Mr. Trump didn't "stand up" to Carrier - he seems to have offered it a bribe. And we're talking about a thousand jobs in a huge economy; at the rate of one Carrier-size deal a week, it would take Mr. Trump 30 years to save as many jobs as President Obama did with the auto bailout; it would take him a century to make up for the overall loss of manufacturing jobs just since 2000.
But judging from the coverage of the deal so far, assuming that the news media will be gullible and innumerate seems like a good bet.
And if and when the reality that workers are losing ground starts to sink in, I worry that the Trumpists will do what authoritarian governments often do to change the subject away from poor performance: go find an enemy.
Remember what I said about Trump Twitter. Even as he took a big step toward taking health insurance away from millions, Mr. Trump started ranting about taking citizenship away from flag-burners. This was not a coincidence.
The point is to keep your eye on what's important. Millions of Americans have just been sucker-punched. They just don't know it yet.
Read my blog, The Conscience of a Liberal, and follow me on Twitter, @PaulKrugman.
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June 29, 2012 Friday
Late Edition - Final
The Upholding of the Health Care Law
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 24
LENGTH: 936 words
To the Editor:
I take back everything negative I ever said about the Supreme Court! (Well, almost everything.) The past year has not been a stellar one for the court. It seems to have taken a decidedly right-wing political view of vitally important issues.
Not only is the decision to uphold the Affordable Care Act (nytimes.com, June 28) constitutionally correct, but it is the right thing for an America struggling with economic and class warfare issues.
While the Affordable Care Act is by no means a perfect law, it accomplishes some marvelous things: quality, affordable insurance that is guaranteed to all; the ability to keep a child on a parent's health insurance until the age of 26; coverage for pre-existing conditions; and the inability of insurance companies to terminate health care benefits when a person becomes seriously ill.
President Obama accomplished what none of his predecessors could in decades of trying.
HENRY A. LOWENSTEIN New York, June 28, 2012
The writer is a former chief executive of health care companies.
To the Editor:
While I applaud the Supreme Court's decision not to throw the country into chaos, by ruling that penalties for not having or providing health insurance are constitutional, many of us who live and breathe health policy realize that the sad truth is that the law won't work.
Paying the penalties -- now deemed taxes by the court -- is usually far more financially favorable than actually having or providing insurance.
Coverage expansion via Medicaid to millions more Americans is a sham given that it presumes providers can absorb the care for these people at reimbursement rates covering a fraction of the actual cost. Current low Medicaid participation rates by providers suggest that new Medicaid recipients will have coverage but nowhere to use it.
Given that the necessary funding mechanism has been validated, Congress needs to cease ideological warfare and modify -- not repeal -- a law that with appropriate tweaks has long-term potential to right the listing health care ''ship.''
CRAIG H. KLIGER San Francisco, June 28, 2012
The writer is a doctor.
To the Editor:
It is always the hope that Supreme Court justices, insulated from the pressures of politics by their lifetime position, will rise above those pressures and really become supreme justices.
In reality, the shining moments are few. But every now and then a justice really does rise above the pressure. For that I tip my hat to Chief Justice John G. Roberts Jr. The court was at a precipice, and he walked it back.
WILLIAM SAROKIN Mount Kisco, N.Y., June 28, 2012
To the Editor:
Chief Justice John G. Roberts Jr.'s legerdemain in finding what Congress clearly intended to be a civil penalty to be a tax seems the opposite of the old saw that if it looks like a duck and quacks like a duck, it must be a duck.
Good grief, what an act of judicial activism -- one that I suspect the left will applaud.
RON HOLDAWAY Draper, Utah, June 28, 2012
To the Editor:
Let's get real about health care reform. Although the Affordable Care Act will bring health insurance to many, it will not bring health care to all or control costs. Millions will still be uninsured or underinsured: one job loss or illness away from bankruptcy. Billions of dollars will continue to be wasted by private, for-profit insurance companies through inflated administrative costs, profits to shareholders and huge salaries for chief executives. These dollars could all be going toward providing health care if we eliminated this unnecessary middleman.
We do not have to look far for a way to do this. Our Medicare program can be expanded to provide care for all. If Congress won't do this, New York State can lead the way with its own single-payer bill. New York could show the nation how to end the disgrace of allowing so many of the 99 percent to suffer and die for lack of health care that, soon, will be affordable only for the 1 percent.
ELIZABETH R. ROSENTHAL Larchmont, N.Y., June 28, 2012
The writer is a doctor.
To the Editor:
For decades we have been faced with two moral injustices in the health care system. The more obvious one -- lack of universal health care insurance -- has now been resolved by the decision to uphold the insurance mandate provision.
Now we can direct our energy to perhaps the greater moral imperative -- providing high-quality health care at a price that will not bankrupt the nation. Those of us on the front lines of designing and delivering this new health care model, whose hallmarks are coordination and standardization of care, elimination of waste and improvement of clinical outcomes, can now breathe a sigh of relief that we are one moral imperative down and only one to go.
ROBERT A. PHILLIPS Senior Vice President UMass Memorial Health Care Worcester, Mass., June 28, 2012
To the Editor:
Finally the Supreme Court has handed down not only the constitutionally right decision but also the morally right decision, especially for the 50 million uninsured people. This health care law is based on a principle that we as a nation need to care for those who are less fortunate as well as respect individual rights.
I am proud of this law and this decision because they affirm once again our sense of community.
STEPHEN LIEM Antioch, Calif., June 28, 2012
To the Editor:
I've been following all the health care reporting and punditry very closely for the past few years, and now, in light of the Supreme Court's decision, there's just one thing I don't understand. How much broccoli do I have to buy to be in compliance, and what's the penalty -- I mean the tax -- if I don't?
MARK R. GODBURN North Canaan, Conn., June 28, 2012
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(Opinionator)
June 28, 2012 Thursday
A Justice in Chief
BYLINE: LINDA GREENHOUSE
SECTION: OPINION
LENGTH: 1156 words
HIGHLIGHT: The decision by Chief Justice John G. Roberts Jr. was deeply pragmatic and saved the Affordable Health Care Act.
The title "chief justice of the United States" is not in the Constitution, and neither was it in the first Judiciary Act by which Congress organized the federal courts. It came into use only casually and gradually, by the late 19th century replacing the favored "chief justice of the Supreme Court of the United States." Even today, people often mangle the title as "chief justice of the Supreme Court."
The mangled title is one that John G. Roberts Jr. would have had trouble claiming on Thursday. In his controlling opinion in the health care case, he spoke largely for himself. In 42 of his 59 pages, he spoke for none of his fellow justices. He led no one.
But the title that he actually goes by, chief justice of the United States, seemed a good fit. He spoke for the country.
His decision to call the mandate a tax and to provide a clearly reluctant fifth vote for upholding it as within the Congressional taxing power was a deeply pragmatic call that saved the Affordable Care Act. Certainly by no coincidence, it also saved the Supreme Court from the stench of extreme partisanship that has hung over the health care litigation from the moment more than two years ago that Republican state officials raced one another to the federal courts to try to erase what they had been unable to block.
There is much to parse in the 193 pages of opinions in National Federation of Independent Business v. Sebelius. In its treatment of Congress's power under the Commerce Clause (only the four most liberal justices would have upheld the law on commerce grounds) and its limited view of federal power to place conditions on states' receipt of federal money, the decision may have implications that extend well beyond this case.
But it is Chief Justice Roberts's extraordinary role that is most intriguing. He has just completed his seventh term as chief justice, and at 57 could well serve another quarter-century or longer. Clearly he is playing a long game. For most of his tenure so far - beginning in year two, after his conservative majority solidified with the departure of Justice Sandra Day O'Connor and the arrival of Justice Samuel A. Alito Jr. - his goal has seemed clear. It has been to turn the court to the right on the hot-button issues of race, religion and abortion, as well as to harness the First Amendment as a deregulatory tool. Did his decision to save the Affordable Care Act, the hottest of all hot buttons so far, divert him from his long-term goals, or offer an alternative, if more oblique, path to them?
The chief justice's mentor and predecessor, Chief Justice William H. Rehnquist, was a master of the long game, willing to tack left if necessary. In 2000, for example, he wrote a majority opinion, over the furious dissents of Justices Antonin Scalia and Clarence Thomas, upholding the Miranda decision against a Congressional effort to declare it inoperative. William Rehnquist didn't like Miranda v. Arizona when the Warren Court decided it in 1966, and he didn't like it any better in 2000, but what he liked even less was an attempted Congressional incursion on the Supreme Court's authority to interpret the Constitution.
Just as clearly, John Roberts doesn't like the Affordable Care Act. He went to great lengths in his opinion to show his total agreement with the plaintiffs' core argument: that the requirement to buy health insurance was an unprecedented effort by Congress to force people into a market they had chosen not to enter, to create commerce where none existed. Justice Ruth Bader Ginsburg's dissenting opinion pierced gaping holes in the chief justice's analysis. But he stuck to his position, coming within an inch of invoking what Justice Ginsburg ironically labeled "the broccoli horrible" and warning that "under the government's theory, Congress could address the diet problem by ordering everyone to buy vegetables."
Since there were four justices who also saw the mandate that way, as Justices Scalia, Thomas, Alito, and Anthony M. Kennedy explained in an unusually structured opinion that all four signed as co-authors, the mandate might have died right there. But then the chief justice abruptly pivoted and declared that because the penalty for not buying insurance functioned as a tax, it could be upheld as a tax and the mandate was therefore constitutional. Justices Ginsburg, Stephen G. Breyer, Sonia Sotomayor and Elena Kagan agreed, making this the only portion of the chief justice's opinion labeled "opinion of the court."
But he didn't speak for the court in the entirety of his tax analysis. Instead, speaking only for himself, he acknowledged that he found it a stretch to call the penalty a tax. "The statute reads more naturally as a command to buy insurance than as a tax," he said, adding that he would have upheld the mandate as a regulation of commerce if he thought the Constitution permitted it. "It is only because the Commerce Clause does not authorize such a command that it is necessary to reach the taxing power question," he said - necessary because "we have a duty to construe a statute to save it, if fairly possible."
This is where the seams of the chief justice's opinion showed, leading to some speculation that the abrupt analytical pivot was actually a last-minute vote switch. For the theory that Chief Justice Roberts pulled back late in the process from declaring the mandate unconstitutional, the best evidence might be external to the opinion, rather than inside it. Around Memorial Day, a number of conservative columnists and bloggers suddenly began accusing the "liberal media" of putting "the squeeze to Justice Roberts," as George Will expressed the thought in his Washington Post column. "They are waging an embarrassingly obvious campaign, hoping he will buckle beneath the pressure of their disapproval and declare Obamacare constitutional," Mr. Will wrote. Although the court has been famously leakproof, Mr. Will and some of the others are well connected at the court, and I wondered at the time whether they had picked up signals that the chief justice, thought reliable after the oral argument two months earlier, was now wavering, and whether their message was really intended for him.
Whatever the scenario, it's possible to see Chief Justice Roberts' role as serving his long-term goals. He made a vigorous argument that Congress had overreached, while at the same time calling on the taxing power as a deus ex machina by which to avoid the logical consequences of his own constitutional analysis. He thus navigated the Supreme Court through a perilous election-year landscape, saving it from the appearance of open partisanship while setting down markers for the game that resumes in October and for the long years ahead. After seven years, he may still be learning, but it's worth remembering that he had a master teacher.
The Two Big Questions on Health Care
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February 18, 2011 Friday
Late Edition - Final
Administration Seeks Clarity From Judge on Health Ruling
BYLINE: By KEVIN SACK
SECTION: Section A; Column 0; National Desk; Pg. 19
LENGTH: 328 words
The Obama administration asked a federal judge on Thursday to clarify whether his recent ruling against the new health care law was meant to block its implementation pending appeals.
The judge, Roger Vinson, of Federal District Court in Pensacola, Fla., ruled on Jan. 31 that the provision requiring most Americans to obtain health insurance was unconstitutional, and that the entire Affordable Care Act was therefore invalid. While the judge did not specifically enjoin the law, he suggested that his ruling should be treated as the ''functional equivalent'' of an injunction.
That led to conflicting interpretations among lawyers for the federal government and for the 26 states that had challenged the law. Some states have continued to carry out its requirements, while others have declared that they consider it effectively dead. Gov. Sean Parnell of Alaska, a Republican, said Thursday that he would stop implementing the law, joining Gov. Rick Scott of Florida in taking a hard stand.
The filing by the Justice Department, which represents the Obama administration in the health care litigation, asked Judge Vinson to clarify that his ruling ''does not relieve the parties of their rights and obligations under the Affordable Care Act while the declaratory judgment is the subject of appellate review.''
The department plans to take the case to the United States Court of Appeals for the 11th Circuit in Atlanta, and has already appealed a second ruling against the law to an appellate court in Richmond, Va. Two other federal judges have upheld the law, and those rulings also are being appealed, with the Supreme Court expected to settle the matter.
The government's filing guides Judge Vinson through a list of provisions that have already taken effect -- tax credits for small businesses, increased Medicare payments to providers, antifraud measures, high-risk insurance pools and grants to states -- and asks whether his ruling intends for each to be suspended.
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November 13, 2015 Friday
Late Edition - Final
Senate Rules Complicate Bid to Repeal Health Care Law
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 829 words
WASHINGTON -- Efforts to repeal the Affordable Care Act have become snarled in the complex rules of the Senate, raising questions about whether the Republican-controlled Congress can fulfill its pledge to send a repeal measure to President Obama.
Repealing the law, passed five and a half years ago, is a goal cherished by Republican politicians, including those running for president, and by elements of the party's base. Mr. Obama has repeatedly vowed to use his veto power if necessary to preserve the health care law, the biggest change in domestic social policy in a generation.
The House on Oct. 23 adopted a budget-reconciliation package that would repeal core elements of the Affordable Care Act. The bill would eliminate the requirement that Americans have health insurance, and that larger employers offer coverage to full-time employees. It would also repeal taxes on medical devices and high-cost employer-sponsored insurance.
In the Senate, Republicans are determined to dismantle or defund the law using a fast-track procedure that requires a simple majority vote, rather than the 60 votes needed for most hotly contested measures.
But the Senate parliamentarian, Elizabeth MacDonough, ruled this week that some provisions of the House-passed bill were not eligible for expedited procedures, aides to Senate leaders of both parties said Thursday. Democrats said the ruling meant that Republicans would need a supermajority of 60 votes, which they do not have, to repeal the individual and employer mandates.
The office of the Democratic leader, Senator Harry Reid of Nevada, issued a statement on Thursday saying, ''The parliamentarian has ruled that Obamacare cannot be repealed through reconciliation.''
''Any fix that repeals the individual or employer mandates will require 60 votes and therefore will not pass,'' the statement added.
However, Republicans said that Mr. Reid had misrepresented the parliamentarian's ruling, the text of which has not been made public. They said that if some provisions of the bill were changed, the Senate could still take up the bill by a simple majority vote and consider it using fast-track procedures.
''When the Senate begins debate on the Obamacare repeal bill, there will be an amendment that preserves the provisions of the House-passed bill, while ensuring that the underlying bill complies with rules that apply only in the Senate,'' said Don Stewart, a spokesman for the Senate majority leader, Mitch McConnell, Republican of Kentucky.
The parliamentarian's ruling complicates the political calculus for Mr. McConnell. He is under enormous pressure from the Senate's right flank and from House Republicans, who have been counting on reconciliation as their final effort to gnaw away at the health care law before the 2016 elections.
The reconciliation process was created by the Congressional Budget Act of 1974. Under the law, a provision of a budget reconciliation bill can be eliminated in the Senate if it ''produces changes in outlays or revenues which are merely incidental to the nonbudgetary components of the provision.''
Repealing the health law mandates would have substantial budgetary effects. The government would lose money: The penalties that would otherwise be paid by individuals and employers who violate the law's requirements. But a repeal would also save money because fewer people would be enrolled in Medicaid, the Congressional Budget Office says.
The parliamentarian evidently concluded that the budgetary effects were ''merely incidental'' to the Republicans' policy objectives.
The exchange on Thursday between the offices of Mr. Reid and Mr. McConnell was part of a larger struggle going on behind the scenes.
Mr. Reid's office asserted that the Senate version of the reconciliation bill ''will have to be more supportive of Obamacare's mandates than the House-passed bill.''
Republicans described that as an effort to scare off conservative Republicans like Senators Ted Cruz of Texas, Mike Lee of Utah and Marco Rubio of Florida, who object to the House bill because it ''repeals only parts of Obamacare,'' as they said recently in a joint statement. They want to go further, demanding a bill that ''fully repeals Obamacare.'' Mr. Cruz and Mr. Rubio are running for president.
Since Republicans hold 54 Senate seats, Mr. McConnell cannot write off such objections. At the same time, he wants the support of moderate Republicans like Susan Collins of Maine and Lisa Murkowski of Alaska, who worry about a section of the bill that would eliminate most federal funds for Planned Parenthood for a year.
Anti-abortion groups like the Family Research Council and the National Right to Life Committee are lobbying for passage of the reconciliation bill because they favor the restrictions on federal funds.
Previous Republican efforts to eviscerate the Affordable Care Act have failed in the Supreme Court and died in the Senate when Democrats controlled that chamber.
URL: http://www.nytimes.com/2015/11/13/us/senate-rules-entangle-bid-to-repeal-health-care-law.html
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February 12, 2015 Thursday
Late Edition - Final
An Ode to Obamacare
BYLINE: By GAIL COLLINS
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 29
LENGTH: 776 words
Let's sing the praises of Obamacare for a minute.
Get back here! I said just for a minute. O.K., it's not the tidiest law in history. You're probably still sulking because you wanted something simple and rational, like a single-payer plan. But it's here, and about 10 million people have health coverage who didn't have it before.
Plus, it's apparently working better than any of us imagined. Here is how great the Affordable Care Act is doing: The Supreme Court is about to hear a challenge to the law, filed on behalf of four Virginia plaintiffs, who claim to have suffered grievous harm by being forced to either buy health coverage or pay a penalty. Lately, reporters have been trying to track down this quartet of pain, and discovered they are:
-- A 64-year-old limo driver who does not seem to be required to do anything under the Affordable Care Act because the cost of even a very cheap health care plan would be more than 8 percent of his income. (People who have to pay more than 8 percent are allowed to just opt out of the whole program and stay blissfully uninsured.) Also, he's a Vietnam veteran and thus presumably eligible for free veteran's health care, making the whole discussion even more irrelevant.
-- A 63-year old man in Virginia Beach who would apparently have been eligible for stupendous savings on health insurance under the new law. And who is also a veteran.
-- A woman who listed her address as a motel where she hasn't been staying since late 2013. And wherever she is, she probably wouldn't have any Obamacare problems because of the 8 percent rule.
-- A 64-year-old woman who seemed to have little or no idea what the case was about. ''I don't like the idea of throwing people off their health insurance,'' she told Stephanie Mencimer of Mother Jones.
That plaintiff, an anti-gay rights activist, also told Mencimer that because of previous health problems, she faced insurance costs of $1,500 a month, a vastly higher premium than she'd pay under Obamacare. Also, The Wall Street Journal determined that her annual rate of pay as a substitute teacher was so low she, too, should be off the hook because of the 8 percent rule. Also, she's about to qualify for Medicare.
Comments by some of the plaintiffs did suggest that they experienced serious pain over the fact that Barack Obama is president. ''... When he was elected, he got his Muslim people to vote for him, that's how he won,'' one told Facebook.
''These are the best they can do?'' asked David Levine, a professor at the University of California Hastings College of the Law.
Wow. Obamacare must be the greatest law in the history of ... laws.
All this may not be enough to get the case thrown out of court. But still. ''It's not hard, frankly, to find plaintiffs who want to take down the government,'' said Neal Katyal, a law professor at Georgetown who formerly served as acting solicitor general. ''The fact that these folks apparently couldn't find four people who actually had a legitimate grievance is very telling.''
The case the Supreme Court is considering would be outrageous even if the plaintiffs were four disabled orphans being threatened with eviction. Linda Greenhouse had a wonderful opinion column recently in The Times explaining the whole thing, but the bottom line is that there is sloppy wording in two Obamacare subclauses, although they're easy to interpret correctly if you read the entire law. The simplest way to clear things up, of course, would be for Congress to just fix the language.
Pop Quiz: Last week the House of Representatives took up the issue of Obamacare and:
A) Voted to tweak the wording in those two subclauses.
B) Voted to repeal Obamacare for the 56th time.
C) Voted to repeal Obamacare for the 67th time.
D) Decided to let everything putter along the way it is and passed a resolution demanding that Beyoncé be given the Grammy for best album.
The answer is either B or C. Even the House of Representatives seems to have lost count.
Critics said that since Republicans were offering no alternative health plan, their position was wildly irresponsible, particular to those Obamacare-covered citizens. This is totally unfair because it overlooks an important provision of the bill requiring three House committee chairs to get together and come up with what Republican leaders called a ''thoughtful replacement strategy.''
We have been looking forward to that thoughtful replacement strategy since the days when everyone was excited about iPads and zombies on TV.
Really, Obamacare is terrific. You can tell by looking at the people who are against it.
I invite you to join me on Facebook.
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February 17, 2015 Tuesday
Late Edition - Final
Open Enrollment Ends; Now the Tax Penalties Start
BYLINE: By MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; THE NEW HEALTH CARE; Pg. 3
LENGTH: 690 words
The Affordable Care Act's second open enrollment period ended on Sunday. Well, almost. Some computer problems over the weekend have led the administration to give a one-week extension to people who tried and failed to sign up.
But its tax penalty season has just begun. For people who didn't sign up for coverage last year, and didn't qualify for a special exemption, the consequences are starting to become clear. As people file their taxes, people who remained uninsured will be hit with penalties of either $95 or 1 percent of their income -- whichever is higher. Those fines rise for people who don't sign up this year, though they won't feel the pain of that decision until next year.
The tax penalties are a key feature of the law, devised as an extra encouragement for reluctant people to enroll in health insurance before they become sick. But awareness remains low among the uninsured, about both signup deadlines and the penalties.
For those who know the trade-offs, the mismatch between the sign-up period and the penalty period doesn't matter much. But for people who don't understand how Obamacare works, unpleasant surprises are likely. Say you didn't buy insurance last year, because you missed the deadline or you were unaware that subsidies would help make it affordable. You let this year's enrollment period slide by for similar reasons. Only after it's too late to sign up will you learn that you've been hit with a hefty fine for last year and will face a bigger one for next year.
That's why Democratic senators have been pressing the Obama administration to offer an extra ''special enrollment period'' for people to sign up at tax time. Health and Human Services Secretary Sylvia Mathews Burwell told Bloomberg News last week that the administration would consider such a proposal, allowing people who faced penalties for 2014 to sign up late for coverage this year.
Many experts in health policy and taxes have long questioned the administration's decision to make insurance enrollment line up with the calendar year. For the last two years, enrollment has run from fall through the winter, with the earliest available coverage beginning in January. But there's no real reason that insurance plans must run from January to December. Since taxes are filed and penalties are assessed in the first few months of the year, a later enrollment period might better synchronize the Affordable Care Act's carrots and sticks.
''The statute says that they have complete flexibility'' to design enrollment periods, said Brian Haile, a former senior vice president at the tax preparation firm Jackson Hewitt who has also worked as a state official. Mr. Haile said the decision to have calendar-year policies is ''stupid and makes no sense,'' given the timing of tax penalties.
Scheduling enrollment for the months surrounding the New Year has other problems, as well. For many of the low-income people the Affordable Care Act is meant to help, the holiday season is the worst possible time to ask people to take on a new financial commitment, since it is typically a time of financial stress. Come tax time, a few months later, many are opening checks for big tax refunds or earned-income tax credits -- and, perhaps, bills for failure to get insurance.
Critics also point out that, if tax filing and insurance sign-up were synchronized, tax preparers could help people sign up. They help many in the target population file taxes, and the family and financial information they collect is similar to what the enrollment website requires.
The administration's openness to a special enrollment period suggests that it may be listening to the criticisms of the current schedule. But its latest regulations tell a different story. Instead of shifting the open enrollment period further into the new year, a current proposal would instead shift the whole thing back into the fall, widening the gap between the timing of sign-ups and tax penalties even more.
The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our weekly newsletter.
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December 27, 2013 Friday
Late Edition - Final
Health Law Cemented, Republicans Debate Next Move
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1290 words
WASHINGTON -- With the first enrollment deadline now passed, Republicans who have made the repeal of President Obama's health care law their central aim are confronting a new reality: More than two million Americans are expected to be getting their health insurance through the Affordable Care Act come Jan. 1.
The enrollment figures may be well short of what the Obama administration had hoped for. But the fact that a significant number of Americans are now benefiting from the program is resulting in a subtle shift among Republicans.
''It's no longer just a piece of paper that you can repeal and it goes away,'' said Senator Ron Johnson, Republican of Wisconsin and a Tea Party favorite. ''There's something there. We have to recognize that reality. We have to deal with the people that are currently covered under Obamacare.''
And that underscores a central fact of American politics since Franklin D. Roosevelt signed the Social Security Act during the Depression: Once a benefit has been bestowed, it is nearly impossible to take it away.
Republicans are considering several ideas for how to proceed. Mr. Johnson argued that Congress should do away with the mandate that most people obtain insurance, but not the online exchanges at the heart of the law. Instead, he said, the options in the marketplaces should be augmented by other choices that fall short of the law's coverage standards, such as catastrophic health plans. (Many policy analysts and insurance companies say such a move would not work, because the mandates are essential to delivering a diverse pool of uninsured people.)
Senator Lindsey Graham, Republican of South Carolina, said that health care strategy was the hottest topic of debate in closed-door political sessions.
''The hardest problem for us is what to do next,'' Mr. Graham said. ''Should we just get out of the way and point out horror stories? Should we come up with a mini Contract With America on health care, or just say generally if you give us the Congress, the House and the Senate in 2014, here's what we will do for you on multiple issues including health care? You become a more effective critic when you say, 'Here's what I'm for,' and we're not there yet. So there's our struggle.''
Senator Kelly Ayotte, Republican of New Hampshire, said she was teaming up with Democrats on a host of incremental changes to the law, such as expanding health savings accounts and repealing a tax on medical devices. And other Republicans are wondering aloud how long they can keep up the single-minded tactic of highlighting what is wrong with the law without saying what they would do about the problems it was supposed to address.
Representative Tom Price, Republican of Georgia, a physician and a prominent conservative voice on health care, is pushing what he calls the Empowering Patients First Act, which would repeal the health care law but keep its prohibition on exclusions for pre-existing conditions in private health insurance.
The bill would allow for insurance to be sold across state lines, push small businesses to pool together to buy insurance for their employees, expand tax-free health savings accounts, cap malpractice lawsuits, and offer tax credits of $2,163 for individuals and $5,799 for families to buy health plans.
The American Action Forum, a conservative advocacy group run by Douglas Holtz Eakin, a former director of the Congressional Budget Office, analyzed the Price plan this month. The group concluded that it would lower insurance premiums by as much as 19 percent by 2023, while leaving the ranks of the uninsured about five percentage points higher than the Affordable Care Act would by then.
Representative Paul D. Ryan of Wisconsin, the Republican vice-presidential nominee in 2012 and a possible 2016 presidential hopeful, is preparing his own health insurance plan for release early next year.
Mr. Ryan's plan will build on one that he and Senator Tom Coburn, Republican of Oklahoma, introduced in 2009, according to aides familiar with it. The proposal, called the Patients' Choice Act, would have eliminated the tax break for employer-provided health care to finance a tax credit of about $5,700 for families and $2,300 for individuals. States would have been asked to create insurance marketplaces like the ones many have created under the Affordable Care Act.
As with the Obama health care law, the Ryan proposal demanded that insurers meet minimum standards of coverage and be prevented from excluding the sick. But instead of mandating penalties for failing to buy insurance, the approach would have automatically enrolled people unless they opted out.
Mr. Price said on Thursday that he was ''cautiously optimistic'' that he, other lawmakers and House Republican leaders could meld the different approaches into one alternative health plan to take to voters -- and possibly the House floor -- in the 2014 election season.
''It's the minority's responsibility to provide a contrast,'' he said. ''It's important that we put forward an upbeat, positive proposal, so the American people know there is an alternative.''
Whether voices like Ms. Ayotte's or Mr. Johnson's will prevail is unclear, given the deep opposition among rank-and-file Republicans. Mr. Graham said that Republicans would probably get away with denouncing the Affordable Care Act through the midterm elections, but that by 2016 they would need to have a fully formed alternative.
White House officials acknowledge that the administration needs to focus on making sure all those who enrolled in health plans actually have coverage on Jan. 1. HealthCare.gov received two million site visits on Monday, the official deadline for coverage starting Jan. 1, and the insurance call center took more than 250,000 calls, said Julie Bataille, a spokeswoman for the Department of Health and Human Services. More than 129,000 people left emails on Monday after finding the website jammed with traffic, and activity remained brisk on Tuesday for those taking advantage of a 24-hour extension.
''Millions of people visited the state and federal marketplaces this week to purchase private health plans,'' said a White House spokeswoman, Tara McGuinness. ''The final tallies are being rounded up, but we believe the deadline encouraged decision-making for hundreds of thousands of families who will have access to care in the new year.''
State-run exchanges had a similar crush. Almost 26,000 people signed up in New York State on the last enrollment day. California enrolled 27,000, and Washington State 20,000. Connecticut beat its expectations with 6,700 new sign-ups.
Some of those rushing to enroll are bound to find problems in January as private insurers struggle to line up federal and state website enrollment with actual policies, a White House official said. And attitudes toward the law are not going to change overnight.
But if Mr. Obama's approval rating on health care is tepid, Congress's is abysmal. Just 19 percent of Americans approve of the way congressional Republicans are handling health care. Still, a New York Times/CBS News poll this month showed that nearly two-thirds of Republicans wanted to have the Affordable Care Act repealed, and most Republican lawmakers are appealing to those constituents.
''A few million people are buying a product that has features they don't want, paying more for it than they should have to pay for it because they had to buy it through this government-mandated mechanism,'' said Senator Patrick J. Toomey, Republican of Pennsylvania. ''I don't think that changes anything fundamentally at all.''
Asked what should be done with the millions of people getting health care through the law, Senator Dan Coats, Republican of Indiana, said, ''Call the White House and ask them.''
URL: http://www.nytimes.com/2013/12/27/us/politics/as-health-law-cements-its-place-gop-ponders-how-to-attack.html
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GRAPHIC: PHOTOS: Senator Ron Johnson of Wisconsin said Congress should eliminate the mandate that most people obtain health insurance. (PHOTOGRAPH BY GABRIELLA DEMCZUK/THE NEW YORK TIMES) (A16)
Senator Kelly Ayotte of New Hampshire said she was working with Democrats on incremental changes to the law, like expanding health savings accounts and repealing a medical devices tax. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
Senator Lindsey Graham of South Carolina said health care strategy was the hottest topic in closed-door political sessions. ''The hardest problem for us is what to do next,'' he said. (PHOTOGRAPH BY CHIP SOMODEVILLA/GETTY IMAGES) (A20)
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January 16, 2017 Monday
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Trump Promises 'Insurance for Everybody' as Health Law Replacement
BYLINE: By MICHAEL D. SHEAR
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WASHINGTON -- President-elect Donald J. Trump said this weekend that he was nearly ready to unveil a plan to replace President Obama's Affordable Care Act with ''insurance for everybody.''
Mr. Trump, in an interview Saturday evening with The Washington Post, said that health care offered under his plan would come ''in a much simplified form -- much less expensive and much better.''
''We're going to have insurance for everybody,'' Mr. Trump said. ''There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us.''
In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign -- that it would be ''great health care'' that left people ''beautifully covered.''
He also offered no explanation of how he would persuade Congress to pass his plan, though he indicated that it would have the backing of the House speaker, Paul D. Ryan of Wisconsin, and the Senate majority leader, Mitch McConnell of Kentucky. Mr. Trump said only that ''I won't tell you how, but we will get approval.''
He seemed to refer to his recent Twitter posts that helped persuade House Republicans to back away from a proposal to gut an ethics office. ''You see what's happened in the House in recent weeks,'' he said.
Top aides to Mr. Trump declined to provide more information about the president-elect's plans. In an interview last week with The New York Times, Mr. Trump said he wanted Congress to repeal the Affordable Care Act and replace it ''very quickly or simultaneously, very shortly thereafter.''
The president-elect told The Post that his plan would be unveiled soon after the Senate confirmed Representative Tom Price, Republican of Georgia, to be the secretary of health and human services.
Achieving the promise of ''insurance for everybody'' has been a goal of health care policy experts for decades, but the political and financial realities have proved problematic. Government-provided health insurance, known as a single-payer plan, has found little political support in Washington. And market-based solutions, like the Affordable Care Act, have proved difficult to carry out.
Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives. And liberals who support Mr. Obama's health care plan -- which provides coverage to 20 million people -- may be wary of the fine print of a program that claims to cover everybody.
Mr. Trump said specifically on Saturday that ''I don't want single-payer.'' He told The Post that he would force drug manufacturers to negotiate better prices with Medicaid and Medicare, the government-run health programs.
Asked how he would force the drug companies to do that, he noted the public pressure that he had exerted on other companies, mentioning his Twitter posts criticizing cost overruns for Lockheed Martin's F-35 fighter jet.
Last week, the House and the Senate began the process of repealing Mr. Obama's health care law by approving parliamentary language that allows them to proceed without the threat of a filibuster by Democrats.
But Republicans have expressed anxiety about the demands from Mr. Trump and others for a quick replacement of the law. Many believe that will require a very complex plan that could be tricky to develop and push through Congress.
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January 1, 2014 Wednesday
Late Edition - Final
The Obamacare We Deserve
BYLINE: By MICHAEL MOORE.
Michael Moore is a documentary filmmaker whose 2007 film ''Sicko'' examined the American health care industry.
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LENGTH: 800 words
TODAY marks the beginning of health care coverage under the Affordable Care Act's new insurance exchanges, for which two million Americans have signed up. Now that the individual mandate is officially here, let me begin with an admission: Obamacare is awful.
That is the dirty little secret many liberals have avoided saying out loud for fear of aiding the president's enemies, at a time when the ideal of universal health care needed all the support it could get. Unfortunately, this meant that instead of blaming companies like Novartis, which charges leukemia patients $90,000 annually for the drug Gleevec, or health insurance chief executives like Stephen Hemsley of UnitedHealth Group, who made nearly $102 million in 2009, for the sky-high price of American health care, the president's Democratic supporters bought into the myth that it was all those people going to get free colonoscopies and chemotherapy for the fun of it.
I believe Obamacare's rocky start -- clueless planning, a lousy website, insurance companies raising rates, and the president's telling people they could keep their coverage when, in fact, not all could -- is a result of one fatal flaw: The Affordable Care Act is a pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go. When right-wing critics ''expose'' the fact that President Obama endorsed a single-payer system before 2004, they're actually telling the truth.
What we now call Obamacare was conceived at the Heritage Foundation, a conservative think tank, and birthed in Massachusetts by Mitt Romney, then the governor. The president took Romneycare, a program designed to keep the private insurance industry intact, and just improved some of its provisions. In effect, the president was simply trying to put lipstick on the dog in the carrier on top of Mitt Romney's car. And we knew it.
By 2017, we will be funneling over $100 billion annually to private insurance companies. You can be sure they'll use some of that to try to privatize Medicare.
For many people, the ''affordable'' part of the Affordable Care Act risks being a cruel joke. The cheapest plan available to a 60-year-old couple making $65,000 a year in Hartford, Conn., will cost $11,800 in annual premiums. And their deductible will be $12,600. If both become seriously ill, they might have to pay almost $25,000 in a single year. (Pre-Obamacare, they could have bought insurance that was cheaper but much worse, potentially with unlimited out-of-pocket costs.)
And yet -- I would be remiss if I didn't say this -- Obamacare is a godsend. My friend Donna Smith, who was forced to move into her daughter's spare room at age 52 because health problems bankrupted her and her husband, Larry, now has cancer again. As she undergoes treatment, at least she won't be in terror of losing coverage and becoming uninsurable. Under Obamacare, her premium has been cut in half, to $456 per month.
Let's not take a victory lap yet, but build on what there is to get what we deserve: universal quality health care.
Those who live in red states need the benefit of Medicaid expansion. It may have seemed like smart politics in the short term for Republican governors to grab the opportunity offered by the Supreme Court rulings that made Medicaid expansion optional for states, but it was long-term stupid: If those 20 states hold out, they will eventually lose an estimated total of $20 billion in federal funds per year -- money that would be going to hospitals and treatment.
In blue states, let's lobby for a public option on the insurance exchange -- a health plan run by the state government, rather than a private insurer. In Massachusetts, State Senator James B. Eldridge is trying to pass a law that would set one up. Some counties in California are also trying it. Montana came up with another creative solution. Gov. Brian Schweitzer, a Democrat who just completed two terms, set up several health clinics to treat state workers, with no co-pays and no deductibles. The doctors there are salaried employees of the state of Montana; their only goal is their patients' health. (If this sounds too much like big government to you, you might like to know that Google, Cisco and Pepsi do exactly the same.)
All eyes are on Vermont's plan for a single-payer system, starting in 2017. If it flies, it will change everything, with many states sure to follow suit by setting up their own versions. That's why corporate money will soon flood into Vermont to crush it. The legislators who'll go to the mat for this will need all the support they can get: If you live east of the Mississippi, look up the bus schedule to Montpelier.
So let's get started. Obamacare can't be fixed by its namesake. It's up to us to make it happen.
URL: http://www.nytimes.com/2014/01/01/opinion/moore-the-obamacare-we-deserve.html
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November 12, 2016 Saturday
Late Edition - Final
Trump Signals Shifting Views of Health Law
BYLINE: By REED ABELSON; Margot Sanger-Katz, Katie Thomas and Julie Hirschfeld Davis contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1559 words
Just days after a national campaign in which he vowed repeatedly to repeal President Obama's signature health care law, Donald J. Trump is sending signals that his approach to health care is a work in progress.
Mr. Trump even indicated that he would like to keep two of the most popular benefits of the Affordable Care Act, one that forces insurers to cover people with pre-existing health conditions and another that allows parents to cover children under their plan into their mid-20s. He told The Wall Street Journal that he was reconsidering his stance after meeting with Mr. Obama on Thursday.
The comments added to a sense of whiplash about the law and its future. More than 100,000 Americans rushed to buy health insurance under the Affordable Care Act on Wednesday, the biggest turnout yet during this year's sign-up period, underscoring that millions of people now depend on the law for coverage.
Beyond Mr. Trump's comments, new plans laid out on his presidential transition website this week deviate from what he had proposed during the campaign, and he added ideas that appeared to more closely align with the mainstream Republican agenda.
The new plans drop all mention of reining in high drug prices, which Mr. Trump had advocated for months, and add new language about modernizing Medicare, a potential nod to congressional efforts to give people vouchers toward buying private health insurance.
''Health care is shaping up as a priority for the Trump administration and Republicans in Congress,'' said Larry Levitt, an executive at the Kaiser Family Foundation, which closely tracks health policy. ''But we still have very little detail about what that really means.''
The health care industry, which invested hundreds of millions of dollars in preparing for business under the Affordable Care Act, is disoriented about what to do next -- and scrambling for ways to avoid a financial shock. A repeal of the act would mean the loss of millions of customers for insurance companies and uninsured people turning to hospital emergency rooms for basic care.
Mr. Trump, in an interview to be broadcast on CBS's ''60 Minutes,'' said the guarantee of coverage for people with pre-existing conditions was ''one of the strongest assets'' of the law. He also said he would try to preserve the measure allowing young adults to remain on their parents' insurance until age 26.
''We're going to do it simultaneously -- it'll be just fine,'' he said, saying that people would not lose coverage when the law was repealed.
Policy experts say that the part of the law that Mr. Trump is rethinking, that prevents insurers from refusing to cover people with costly medical conditions, only works financially for insurers if there are plenty of healthy people also buying insurance. If only sick people enroll, premiums would soar. To get healthy people covered, the existing law includes generous subsidies to help more people to afford a policy and taxes people who don't buy insurance.
Industry executives say their first priority is to persuade Mr. Trump and the new Congress to replace the law with some way for people to continue getting coverage.
The problem is that, until now, top executives from the biggest insurers have not heard from Mr. Trump or his close advisers about his plans. In fact, the industry as a whole made no contingency plans for a Trump victory and does not yet appear to have developed a strategy. In the last few days, executives have huddled hurriedly with their boards and advisers to discuss how to react.
In mapping out various election result possibilities, ''this wasn't on the sheet,'' said Mark Bertolini, the chief executive of Aetna. ''We had no idea how to approach it.''
The consequences are urgent. About 22 million Americans would be without insurance if the law were repealed. The state marketplaces, where about 10 million of those people buy insurance, would no longer exist. The millions of others who were newly eligible for Medicaid would also lose coverage.
''I'm concerned about the fear factor of what is going on,'' said Bernard J. Tyson, the chief executive of Kaiser Permanente, the system based in California that includes hospitals, doctors and an insurance plan. He said the company was already getting calls from people worried about whether they would still be able to get coverage. Both federal officials and insurance executives say people should not hesitate to sign up during the current open enrollment period.
Terri Marsh, 61, in Goose Creek, S.C., did not hesitate to sign up again for a Blue Cross plan as soon as she could. ''Insurance is something you have to have,'' she said. Before the marketplace plans were available, she had been without coverage for five years, despite having a serious inflammatory disease.
''Because I have a pre-existing disease that is off the wall for them, I could not get insurance,'' she said. Without getting the coverage through the law, she said, ''I could possibly be dead.''
Yet Republicans have seized on some areas where the law is struggling and in the government-run insurance marketplaces in particular. This month, for example, Republicans highlighted the sharp rise in the average price of an insurance plan on the marketplace -- 25 percent -- as proof that the law was fatally flawed. Mr. Bertolini warned that rates could go even higher next year.
Without a 60-vote supermajority in the Senate, Republicans will probably be unable to repeal the entire Affordable Care Act. But they can eliminate several consequential provisions through a special budgetary process called reconciliation.
Last year, the Senate passed a reconciliation bill that undid large portions of the health bill. The House passed it. President Obama vetoed it.
The bill would have eliminated the expansion of Medicaid coverage for Americans near or below the poverty line. It would have eliminated subsidies to help middle-income Americans buy their own insurance on new marketplaces. It would have eliminated tax penalties for the uninsured, meant to urge everyone to obtain health insurance. And it would have eliminated a number of taxes created by the law to help fund those programs. (It was written to kick in after two years, meaning the programs would not disappear immediately.)
Many parts of the law cannot be repealed through reconciliation. Among them are reforms to the Medicare program, a provision that requires insurers to cover young adults on their parents' policies, and requirements that health insurers sell policies to anyone regardless of their health history. Those parts of the law are very likely to remain law.
Crucial aspects of the bill can be undone in a number of other ways, too. The administration could simply halt efforts to sign people up for the state marketplace plans. Or Congress could eliminate the federal subsidies that help millions of people afford a plan. Either one of those moves would most likely cause far fewer people to sign up for insurance, leading to instability or collapse of the insurance marketplaces.
''There are a lot of different triggers that can be pulled,'' said Benjamin Isgur, the leader of the PwC Health Research Institute.
For the insurers and hospitals, the challenge is to persuade President-elect Trump that an alternative to the online marketplaces is necessary.
Insurers will feel the loss of customers both in the individual market and under state Medicaid programs. While most are well diversified into other areas of insurance, the Affordable Care Act was seen as a way to forestall the steady erosion in employer-based insurance. The companies spent years and millions investing in being able to sell new policies through the state marketplaces, operating under an entirely new model.
Hospitals, however, are likely to be the biggest losers. Under the law, they agreed to get less money from the government, essentially in exchange for having to cover fewer uninsured people.
''If repeal happens, are there voices in the industry loud enough to replace it?'' said Sam Glick, a partner at Oliver Wyman, a consulting firm.
Executives insist that the proposals that have been discussed before, including by Paul D. Ryan, the speaker of the House and a Republican, laid out how to replace the coverage and would allow people to transition to different options.
The Trump administration and Congress ''are not going to pull out the rug from people,'' said Dr. J. Mario Molina, the chief executive of Molina Healthcare, a for-profit insurer. He predicted that the earliest the law could be repealed was 2018, and that it would be replaced with something like a modified version of Medicaid, the government insurance for poor people. ''The debate is not around the what, but around the how,'' he said.
Because Mr. Trump has been short on detailing exactly what he plans to do, though, many in the industry argue they cannot prepare a strategy in advance. He has said broadly that he wants to repeal the law, for example, and give states more control over Medicaid programs. He has talked about being able to sell insurance across state lines and has recently discussed a return to the state programs that existed to help cover people with serious medical conditions.
''This is Day 1 of figuring out what all of this means,'' Mr. Glick of Oliver Wyman said Wednesday.
URL: http://www.nytimes.com/2016/11/12/business/insurers-unprepared-for-obamacare-repeal.html
LOAD-DATE: November 12, 2016
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GRAPHIC: PHOTOS: Above left, a woman searching for a policy on healthcare.gov, part of the Affordable Care Act. Above right, House Speaker Paul D.Ryan, who has advocated the law's repeal. Removing the health law without replacing it would probably mean that more uninsured people would rely on hospital emergency rooms for basic care. The topic is likely to be a priority for the new administration. (PHOTOGRAPHS BY KAREN BLEIER/AGENCE FRANCE-PRESSE -- GETTY IMAGES
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(You're the Boss)
June 23, 2011 Thursday
Debating Whether Businesses Will Continue to Offer Health Insurance
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 864 words
HIGHLIGHT: Employers may see an opportunity to shed their insurance burden once 2014 arrives, but the system that's coming is so new and different - and complicated - that it seems foolish to presume this will happen right away.
Two weeks ago, the international consulting firm McKinsey & Company threw itself into the rancorous partisan debate over the 2010 health care overhaul by publishing research that appeared to predict that many employers would dump their health insurance plans when the new law fully took effect in 2014. The new law offers subsidies to help low-income people purchase health insurance from state-run exchanges, and it also penalizes companies with more than 50 employees when they fail to offer those employees affordable coverage. As McKinsey notes, paying the penalty will cost less than providing the insurance, so companies could profit by socializing that cost.
Nonetheless, the finding was surprising, and controversial, because, as The Agenda reported in April 2010 (and also in 2009), most economists say they believe that a mix of market pressures, a tax incentive and the penalty will deter all but a relative handful of employers from casting off their health insurance plans. The Obama administration slammed McKinsey's apparent prediction, and Senate Democrats demanded that the consultants release the proprietary methodology behind it. For several days, McKinsey refused.
I say "appeared to predict" because on Monday, when McKinsey finally released the methodology, it came with a statement insisting that the survey had done no such thing. Rather, "it captured the attitudes of employers and provided an understanding of the factors that could influence decision-making related to employee health benefits." Two paragraphs later, the statement continued, "We understand how the language in the article could lead the reader to think the research was a prediction, but it is not."
The Agenda understands, too: The original article was titled "How U.S. Health Care Reform Will Affect Employee Benefits." Its second sentence declared, "While the pace and timing are difficult to predict, McKinsey research points to a radical restructuring of employer-sponsored health benefits following the 2010 passage of the Affordable Care Act." One word that appears frequently throughout the article is the future-tense "will," not the conditional "could" - as in, "30 percent of employers will definitely or probably stop offering E.S.I." - employer-sponsored insurance - "in the years after 2014." (The Times reported Tuesday that Democrats were not impressed by McKinsey's explanation.)
Still, the distinction between making predictions and capturing present attitudes - or, really, aspirations - is important. It should come as no surprise that employers, given their choice, would rather focus on their business than go through the administrative hassle of arranging health insurance for their work force. Companies probably wouldn't offer it now if their employees didn't demand it and weren't willing to trade away a portion of their wages to have it. (Economists say that, contrary to broad public perception, employers don't pay more to offer health insurance. Instead, insurance is merely a component of total pay - and employers that stopped offering it would have to provide some other, well, compensating compensation.)
Strikingly, the overall impression from the McKinsey article is that employees' views count for little in the coming debate over whether employers will provide health care - or that they'll accept whatever employers choose to offer. Here, for example, are two findings from McKinsey, based on separately conducted consumer research: 85 to 90 percent of employees would still work for their current company even after it dropped health insurance coverage, but only 60 percent would demand increased compensation to make up for it. That may, or may not, be true in 2011 - we'll leave it to others to assess the soundness of McKinsey's survey techniques - when the prospect of an employer dropping health insurance is too abstract for many in the work force to think seriously about what their coverage is worth. But who can say how they'll think in 2014, as the new system is put in place - accompanied, no doubt, by extensive media coverage?
Employers might see an opportunity to shed their insurance burden once 2014 arrives, but the system that's coming is so new and different - and complicated - that it seems foolish to presume this will happen right away, if at all. The new law could ultimately dismantle the underpinnings of workplace-provided insurance, but employees, too, will probably have something to say about this. It could take years, maybe even a generation, for people to grow comfortable with buying insurance on their own, and if they continue to insist on insurance from their employer, or prospective employer, in the meantime, companies are likely to comply. That's what happened in Massachusetts after that state passed its own health care reform in 2006, as health economist Jonathan Gruber told The Agenda the last time we looked at this. There, employer-sponsored coverage actually increased.
How the Health Care Law Affects Your Business
Looking to the Affordable Care Act For Help
Is the Health Care Plan a Good Thing?
Small Firms May Not Keep Current Health Plans After White House Decision
N.F.I.B. Joins Suit Against Health Reform
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February 7, 2017 Tuesday
Late Edition - Final
Reality Chills Heated Words on Health Law
BYLINE: By MICHAEL D. SHEAR and ROBERT PEAR; Thomas Kaplan contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1179 words
WASHINGTON -- Asked at a confirmation hearing two weeks ago if he was working with President Trump on a secret plan to replace the Affordable Care Act, Representative Tom Price, Mr. Trump's nominee for secretary of health and human services, smiled broadly and answered: ''It's true that he said that, yes.''
The committee room, filled with health care lobbyists, consumer advocates and others with a vital stake in the future of the health care law, erupted with knowing laughter at Mr. Price's careful formulation. For those following the issue closely, it has been an open secret that the fledgling Trump administration is a long way from fulfilling one of Mr. Trump's most repeated campaign promises.
In a brief aside in an interview with Bill O'Reilly of Fox News broadcast before the Super Bowl on Sunday, Mr. Trump went further than he ever has in acknowledging the reality that any hope of quickly replacing the Affordable Care Act has been dashed.
''Yes, I would like to say by the end of the year, at least the rudiments, but we should have something within the year and the following year,'' the president said.
That admission is sure to be a serious disappointment for the president's most fervent supporters, who sent him to Washington believing that he would move quickly to dispatch the health law.
Soon after he was elected, Mr. Trump reacted to Republican suggestions of a delay in replacing the health act by insisting that repealing and replacing the law must happen at about the same time.
Now, Mr. Trump and his Republican allies on Capitol Hill have recast their ambitions for a rapid-fire repeal, talking privately and publicly about a more deliberative process that could be phased in over weeks or months.
''The political uncertainty surrounding repeal is growing,'' said Dan Holler, a spokesman for Heritage Action for America, the advocacy arm of the conservative Heritage Foundation. ''If the House has not passed a repeal bill and sent it to the Senate by mid-March,'' Mr. Holler added, ''that would be serious cause for concern.''
The uncertainty is already reflected in the way Republicans talk about the health care law. Some now talk about ''repairing'' the law, rather than repealing it entirely. And in a twist of fate, many are facing tough, angry questions at town hall meetings -- the mirror image of 2009, when Tea Party activists assailed Democrats who supported the law.
A crowd of protesters gathered outside a town meeting in California held over the weekend by Representative Tom McClintock, who was escorted by police officers as he left the event, according to news reports. Representative Gus Bilirakis of Florida faced 200 angry supporters of the health care law at a meeting on Saturday.
In the interview that aired on Sunday, Mr. Trump appeared to admit that his get-it-done braggadocio about a swift repeal of President Barack Obama's signature legislation was instead becoming a drawn-out Washington process that could stretch for months or even years.
Mr. Trump's comment prompted what is becoming a ritual on Capitol Hill: trying to interpret the words of a president who is not steeped in the rhythms of the legislative process.
''I don't really know what he's referring to in terms of a year,'' said Senator John Cornyn of Texas, the No. 2 Senate Republican. He added that Republicans hoped to get their replacement plan in place ''well before that.''
Senator John Thune of South Dakota, the No. 3 Republican in the chamber, said the Senate hoped to work ''systematically, in a step-by-step way.'' But he conceded ''that may take longer than, you know, than people at first thought.'' He expressed hope that ''at some point,'' if Mr. Trump has a health care proposal, ''he'll engage and that we'll be able to work together with him on it.''
Few of Mr. Trump's campaign promises rivaled the one he made to dismantle the Affordable Care Act. He repeatedly called it a ''disaster'' and vowed that, if elected, he would immediately replace it with a new and better overhaul of the health care system.
Mr. Trump issued an executive order on his first day in office directing agencies to do what they could to provide relief from the health care law to people and businesses. But his power to unravel the law unilaterally is limited.
Michael F. Cannon, the director of health policy studies at the libertarian Cato Institute, warned that the delay in taking action in Congress threatened to undermine the momentum for significant change.
''Every day they delay,'' he said, ''the problems of the Affordable Care Act get worse.''
Insurance executives say immediate action is needed to stabilize insurance markets, or else more insurers will withdraw from the public marketplaces created under the Affordable Care Act. Insurers deciding whether to participate in the market in 2018 face a May deadline for submitting rate proposals to the federal government.
The turnabout has made Democratic lawmakers gleeful. Their refusal to work with Republicans unless a full-blown repeal is taken off the table has helped to ratchet up pressure on the president and his allies to come up with a replacement before eliminating a health care program that delivers insurance to about 20 million Americans.
''The reality of the difficulty of getting things done is sinking in,'' Senator Chuck Schumer of New York, the Democratic leader, said of Mr. Trump and Republicans in Congress. ''Democrats are feeling much better that there's some chance of success.''
Democrats have also been encouraged by opinion polls showing that the public is increasingly supportive of the health care law. A Quinnipiac University poll released last month found that 84 percent of people believe Congress should not repeal the Affordable Care Act until a replacement plan is in place.
That is proving especially difficult for Republicans to accomplish in the time frame that Mr. Trump once called for.
In the first 10 days of the new Congress, lawmakers passed a budget resolution clearing the way to repeal major provisions of the law and neutralize the threat of a Democratic filibuster. By Jan. 27, four congressional committees were supposed to have drafted legislation gutting the 2010 health care law. But it soon became clear that the deadline was neither realistic nor enforceable.
Republican leaders in the House and the Senate now envision a more conventional legislative process. In an interview on Sunday, Speaker Paul D. Ryan insisted that Republicans believed it was their duty to ''step in front of this crash and rescue people from this collapsing health care system and replace it with something better.''
But Mr. Ryan has also been clear for weeks about the reality of the legislative timeline.
''The question there is: How long will it take for markets to be put in place, for markets to adjust?'' Mr. Ryan told reporters on Jan. 5. ''That question we don't know the answer to.''
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URL: http://www.nytimes.com/2017/02/06/us/politics/obamacare-tom-price-trump.html
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GRAPHIC: PHOTO: Representative Tom Price of Georgia on Jan. 24 at a confirmation hearing to become secretary of health and human services. (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A13)
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July 15, 2016 Friday 00:00 EST
Makers of Humira and Enbrel Using New Drug Patents to Delay Generic Versions
BYLINE: ANDREW POLLACK
SECTION: BUSINESS
LENGTH: 1062 words
HIGHLIGHT: Six years after the Affordable Care Act cleared the way for biosimilars, as the generic versions of biotechnology drugs are called, progress has been slow.
The best-selling drugs Humira and Enbrel have a lot in common. They both use biotechnology to treat rheumatoid arthritis, psoriasis and other autoimmune diseases. And they come with giant price tags approaching $50,000 a year.
Now the two companies behind the competing drugs have found common ground in keeping those prices so high: They are deploying new patents to prevent patients and insurers from getting two essentially generic versions of the drugs for less money.
This week, advisers to the Food and Drug Administration recommended approval of the near generic versions. But the patents could delay introduction. And even if the drugs get to market, some patient groups say they will resist efforts by insurers to force them to use the less expensive drugs.
The various developments show that six years after the Affordable Care Act cleared the way for biosimilars, as the generic versions of biotechnology drugs are called, progress has been slow. Only one biosimilar, a mimic of the white blood cell booster Neupogen, is available to patients.
"It's a lost opportunity to reduce health care costs," said Fiona M. Scott Morton, a professor at the Yale School of Management.
By contrast, according to a study she did, biosimilars have been available in Europe for years and have reduced costs for some drugs as much as 80 percent, though in many cases far less.
Humira and Enbrel are biologics, which are complex proteins made in living cells. Seven of the world's top 10 selling drugs in 2015 were biologics. Humira was No. 1 with $14 billion in global sales and Enbrel was No. 3 at $8.7 billion, according to the website PharmaCompass.
Until the 2010 Affordable Care Act authorized the F.D.A. to approve biosimilars, biologics were insulated from the generic competition. Since then, it has taken time for the F.D.A. to lay out the ground rules for biosimilars. Some rules are still not in place.
"They are still behind when it comes to creating the infrastructure to push these molecules ahead," said Bertrand C. Liang, chairman of a biosimilars council set up by the Generic Pharmaceutical Association.
Things now seem to be heating up, however. A biosimilar that mimics Johnson & Johnson's autoimmune disease drug Remicade was approved by the F.D.A. in April. It is not yet on the market, in part because of patent issues. But Pfizer, which owns the marketing rights, hints that it is planning to introduce it this year.
There are about 60 biosimilars in clinical trials aimed at approval in the United States or Europe, according to Sanford C. Bernstein & Company, including 13 versions of Humira.
The makers of the brand-name biotechnology drugs for years argued that biologics were such complex molecules that they could not be exactly copied. It is for that reason the copycats are called biosimilars rather than generics.
Still, that argument is now falling by the wayside, in part because some of those same brand-name companies are developing biosimilars themselves.
Amgen, for example, was on both sides of this week's debates among the F.D.A. advisers. The company developed the Humira biosimilar, but it also owns Enbrel, which is threatened by biosimilars.
At the meeting on Tuesday, the advisory committee voted 26 to 0 that Amgen's Humira knockoff was similar enough to the original drug to be approved for essentially all uses of Humira. It made that decision even though Amgen had tested the drug in patients with only two of those diseases, rheumatoid arthritis and psoriasis.
The next day it voted 20 to 0 in favor of a broad approval of the Enbrel biosimilar, which was developed by Sandoz, the generic division of Novartis, and tested only in patients with psoriasis.
While the F.D.A. itself is expected to approve the two biosimilars in the coming months, patents might keep them off the market.
The main patent on the composition of Humira expires at the end of this year. But AbbVie, the company behind Humira, has amassed more than 70 newer patents, mostly in the last three years, covering formulations of the drug, manufacturing methods and use for specific diseases. It says these ancillary patents should protect its crown jewel, which accounted for 61 percent of its revenue last year, until at least 2022.
"Any company seeking to market a biosimilar version of Humira will have to contend with this extensive patent estate, which AbbVie intends to enforce vigorously," Richard A. Gonzalez, the company's chief executive, said last October.
Enbrel's main patent has already expired. But the drug is now protected by two "submarine patents," so called because they wended their way through the patent office over a long period of time, hidden from view. Even though the inventions involved were made in the early 1990s, the patents were not granted until 2011 and 2012 and last until 2028 and 2029.
If those patents hold, by 2029, Enbrel will have been on the market without generic competition for 31 years, far longer than the 12 years of exclusivity for biologics called for in the Affordable Care Act. Humira has been on the market for 14 years.
Humira and Enbrel are direct competitors, but that by itself has not led to much price competition. List prices of the two drugs have been rising in lock step and are nearly triple what they were in early 2008, according to SSR, an investment research firm.
Biosimilar developers might be able to circumvent the ancillary patents and some are challenging their validity at the patent office.
"Biosimilar developers are realizing that these follow-on patents are vulnerable," said Oona Johnstone, a patent lawyer at Wolf Greenfield. However, Amgen failed in its first attempt to invalidate two patents on Humira formulations.
Even if biosimilars get to market, their impact will depend on how widely they are used.
At the F.D.A. advisory committee meeting, one issue that could limit the adoption of the biosimilars came into view. Numerous patient and doctor groups argued that insurers should not be allowed to switch patients to a biosimilar if they were doing well on the brand-name drug, because the products are not absolutely identical.
"It may be essentially equivalent to a scientist or an insurance company, but it's not to the patient," said Seth Ginsberg, president of the Global Healthy Living Foundation, a patient advocacy group. The foundation counts AbbVie and Amgen among its corporate sponsors.
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April 27, 2017 Thursday
Late Edition - Final
Trump Should Save Obamacare
BYLINE: By NANCY-ANN DEPARLE and PHIL SCHILIRO.
Nancy-Ann DeParle, a deputy chief of staff for policy for President Barack Obama, is a partner in Consonance Capital Partners, a health care-focused private equity firm. Phil Schiliro, director of White House legislative affairs from 2009 to 2010, is a managing director of Schiliro Barnett, a consulting firm.
SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 27
LENGTH: 879 words
Imagine waking up to this headline: ''Trump Saves the Affordable Care Act.''
It sounds far-fetched -- and would certainly be an audacious move -- but President Trump could pull it off. He has already changed course when presented with new information: After all, China is no longer a ''currency manipulator,'' and NATO is no longer ''obsolete.''
In this case, improving the Affordable Care Act would not only be good policy for millions of Americans but would also be farsighted politics for Mr. Trump. The obvious obstacles are his repeated claim that the law is a ''disaster'' and internal Republican Party dynamics. But his endorsement of the House Republican bill last month ended in one of the biggest embarrassments of his first 100 days. And the new attempt this week to revive the effort might have a similar fate. So he shouldn't let his past criticisms preclude him from pivoting from ''repeal and replace'' to ''repair and rebrand.''
A rebranded Affordable Care Act would be consistent with the vision Mr. Trump offered during the campaign. Then, he promised that everyone would be ''beautifully covered,'' with ''much lower deductibles,'' and ''taken care of much better than they're taken care of now.'' He said he wouldn't cut Medicaid and would provide coverage for those who can't afford care.
As former White House aides who worked on the health care law, we remember why reform was desperately needed. Our system was broken, with 50 million uninsured, skyrocketing premiums and no relationship between cost and quality.
That was then. Now we have the lowest percentage of uninsured Americans on record and the slowest rate of inflation in health care spending in 50 years. Medicare beneficiaries have saved $27 billion on prescription drugs, quality of care is improving, and nearly 600,000 unnecessary hospital readmissions have been prevented.
Still, the law isn't perfect. Too many hardworking families struggle to pay their medical bills, deductibles are often too high, and some insurance marketplaces need more competition.
The original House Republican bill would have made these problems worse. Premiums would have spiked for most families in the individual market (especially for older people), 24 million would have lost coverage, and over $800 billion would have been cut from Medicaid, a program that provides lifesaving help to severely disabled children, the frail elderly and the poor. Given this, Mr. Trump's support for the House bill was baffling. And the latest version -- which tries to reflect the House Freedom Caucus principle that the federal government should have no role in health insurance -- moves even farther from his campaign promises.
The answer to the law's shortcomings isn't repeal. Many House Republicans are caught in a classic ''inside the Beltway'' dynamic -- the more they repeat the repeal rhetoric, the more converted they become to the cause. But that self-perpetuating loop isn't the country's reality.
There's still a winning hand for President Trump on health care, but it's not the one he's playing. ''Repair and rebrand'' would take advantage of Mr. Trump's background as a businessman and his interest in expanding the private sector. What the Affordable Care Act needs most is more customers -- and federal officials taking actions to increase enrollment, strengthen private plans and ensure the marketplaces will function properly. With a few smart adjustments, this will foster a virtuous cycle of lower costs and expanded competition and coverage options for millions of working-class voters.
First, Mr. Trump should eliminate any doubt that the cost-sharing subsidies that limit out-of-pocket expenses for over eight million Americans and stabilize the insurance markets will continue. He can do this by continuing to fund the subsidies through existing authority and by fighting a House Republican lawsuit challenging the program. Another alternative would be to support a bipartisan, permanent legislative proposal.
Second, he should make clear that he will faithfully execute the law and instruct his secretary of health and human services, Tom Price, to maximize enrollment efforts and finalize rules that improve affordability, instead of undermining coverage. That will give insurers the confidence to stay in the marketplaces and lower premiums.
Third, Mr. Trump should use his singular marketing skills to highlight the very real benefits of coverage. Past enrollment efforts have been constrained by insufficient resources and partisan attacks. Mr. Trump can create innovative ways to persuade people to enroll. Increasing enrollment will bolster private plans and marketplaces that are lagging, and potentially make insurance cheaper in many states.
Finally, the president is well positioned to persuade governors and legislatures in the 19 states that haven't expanded Medicaid -- almost all of which he won in the election -- to cover four million more people. This would bring billions in benefits to their hospitals and help combat the opioid crisis.
By keeping faith with his own voters, Mr. Trump has an opportunity to combine good substance with good politics.
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URL: https://www.nytimes.com/2017/04/27/opinion/how-trump-could-save-obamacare-and-help-himself.html
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The New York Times
March 18, 2014 Tuesday
Late Edition - Final
G.O.P. House Members Plan Tour to Test Alternatives on Health Care
BYLINE: By JONATHAN WEISMAN
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 850 words
WASHINGTON -- Senior House Republicans -- struggling to find consensus for health care legislation to replace the Affordable Care Act -- are planning to test ideas in April at town-hall-style meetings that could provide a path toward a long-promised alternative to President Obama's signature legislative achievement.
The ''House ObamaCare Accountability Project'' is still months away from producing actual legislation. With Democrats opposed, Republican leaders will have a hard time finding enough votes for any plan, and Speaker John A. Boehner of Ohio remains cool to guaranteeing a vote.
But a road map is developing.
''It's important to show the American people that there is a better approach to improving health care for Americans than Obamacare,'' said Representative Kevin McCarthy of California, the majority whip. ''Unlike the president and congressional Democrats, we have been listening to the American people, and what Americans want is affordability, greater flexibility and access to care, which we are focused on achieving.''
Republicans have been talking about repealing and replacing Mr. Obama's health care law ever since they took control of the House in 2011, with dozens of votes to repeal it. But the ''replace'' part of the equation has been elusive. Some Republicans say any detailed health care alternative will give Democrats a target and allow them to regain footing just as attacks on the law are taking a political toll. And the most ardent conservatives are likely to oppose any health care legislation that envisions a role for the government.
With every passing week, the Affordable Care Act is changing the political terrain, Republican leadership aides concede. The Department of Health and Human Services announced on Monday that enrollment in private health plans through the health care exchanges had passed the five million mark, with two weeks to go before the first sign-up period ends.
That may be below the goal of seven million set initially by the administration in internal documents, but the final number will not be far below that, and it does not count millions more enrolled through an expansion of Medicaid.
Still, Representative Eric Cantor of Virginia, the majority leader, surprised Republicans in late January when he promised a vote this year on a detailed alternative to the law. That left it to Mr. McCarthy; Representative Cathy McMorris Rodgers of Washington, the Republican conference chairwoman; and about 30 others to find consensus.
''I think talking about our positive ideas is a good contrast with what's not working and what I think are bad ideas on health care,'' said Representative Tim Griffin, Republican of Arkansas and part of the effort. ''It's not a binary choice. It's not Obamacare or nothing.''
Republicans emphasize that they have a way to go, and may not succeed, and Mr. McCarthy said he was operating on no time line.
''Right now, our goal is to discuss policy alternatives and build consensus,'' he said.
The group has begun combing through a half-dozen bills already written by House Republicans to find a common core. So far, three proposals appear in all of the bills: expanding tax-free health savings accounts to help individuals pay for private health insurance, augmenting federal or state ''high-risk pools'' where people with pre-existing medical conditions could seek insurance with government assistance and allowing small businesses to pool together to purchase health plans.
Many of the bills also include provisions limiting medical malpractice suits and judgments; guaranteeing renewal of health plans when people change jobs, regardless of their health; and allowing people to purchase insurance plans across state lines.
None of those are new ideas, but House Republicans involved in the project want to find new ways to explain why their ideas would save most health care consumers money, especially compared with the rising out-of-pocket costs they say are driven by the health care law.
That message will be road-tested by about 30 House Republicans over the spring recess from April 11 to 27.
''This group will go out, have town hall meetings to say: 'Here's how Obamacare has failed. Here's why. Here's what we're going to do,' '' said Mike Long, a spokesman for Mr. McCarthy. ''We have to make this a pocketbook issue.''
Messaging, however, might be the easy part. Legislating on big, divisive issues has been elusive for House Republicans for years. Last April, facing Democrats who said a repeal of the Affordable Care Act would expose millions of Americans with pre-existing medical conditions to economic peril, Mr. Cantor tried to devise a solution.
His legislation would shift billions of dollars from a preventive health care fund in the Affordable Care Act to state-based high-risk pools for sick people seeking insurance. Conservatives revolted, rejecting what they saw as too large a role in health care for the government, and the bill died.
''In terms of synthesizing the ideas of the conference, in terms of a time frame, I don't know,'' Mr. Griffin said. ''But I do know we're making progress.''
URL: http://www.nytimes.com/2014/03/18/us/politics/gop-house-members-plan-tour-to-test-alternatives-on-health-care.html
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GRAPHIC: PHOTO: From left, Representatives Kevin McCarthy, Eric Cantor and Richard Hudson and Speaker John A. Boehner last month at a news conference after a meeting of House Republicans at the Capitol. (PHOTOGRAPH BY J. SCOTT APPLEWHITE/ASSOCIATED PRESS)
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November 8, 2014 Saturday
Late Edition - Final
Justices to Hear New Challenge to Health Law
BYLINE: By ADAM LIPTAK; Reed Abelson contributed reporting from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1218 words
WASHINGTON -- The Supreme Court on Friday agreed to hear a new challenge to the Affordable Care Act, potentially imperiling President Obama's signature legislative achievement two years after it survived a different Supreme Court challenge by a single vote.
The case concerns tax subsidies that currently help millions of people afford health insurance under the law. According to the challengers, those subsidies are being provided unlawfully in three dozen states that have decided not to run the marketplaces, known as exchanges, for insurance coverage.
If the challengers are right, people receiving subsidies in those states would become ineligible for them, destabilizing and perhaps dooming the law.
The Obama administration said it would mount a vigorous defense in the Supreme Court.
''This lawsuit reflects just another partisan attempt to undermine the Affordable Care Act and to strip millions of American families of tax credits that Congress intended for them to have,'' said Josh Earnest, the White House press secretary. ''We are confident that the financial help afforded millions of Americans was the intent of the law and it is working as Congress designed.''
Scott Pruitt, Oklahoma's attorney general, said he welcomed the Supreme Court's decision to hear the case. The administration, he said, ''cannot ignore the plain language in a statute and rewrite laws with which they disagree.'' He added, ''This Supreme Court review will provide Oklahoma and the 35 other states that did not establish state-based exchanges with immediate and conclusive clarity as to their rights and obligations under the A.C.A. so that the states may make appropriate health care policy decisions.''
The case is likely to be argued in February or March, and a decision will probably arrive in June, three years after the court ruled that Congress had acted constitutionally in enacting the law.
In a supporting brief urging the court to hear the case, several Republican lawmakers said the law as currently enforced would result in ''tens of billions of dollars of unlawful spending in the next year, and hundreds of billions over the next decade.''
Representative Nancy Pelosi, the House minority leader, said the court's move was a surprise. ''It's troubling that they would even consider this,'' she said. ''The language is very clear. The intent of Congress is very clear.''
The central question in the case, King v. Burwell, No. 14-114, is what to make of a provision in the law limiting subsidies to ''an exchange established by the state.'' (If states do not establish their own exchanges, the health care law requires the federal government to run them instead.)
The challengers say the provision means that only people in states with their own exchanges can get subsidies. Congress made the distinction, they say, to encourage states to participate.
But the Internal Revenue Service has issued a regulation saying subsidies are allowed whether the exchange is run by a state or by the federal government. The challengers say that regulation is at odds with the law.
In response, Solicitor General Donald B. Verrilli Jr. told the justices that the I.R.S. interpretation was correct, while the one offered by the challengers was ''contrary to the act's text and structure and would render the act unrecognizable to the Congress that passed it.''
Health insurance companies reacted cautiously to the announcement. ''This issue is now in the hands of the justices, but it's clear that significant policy changes would be required to ensure an affordable and stable market for consumers were the court to rule against the government,'' Clare Krusing, the director of communications for America's Health Insurance Plans, the industry trade group, said in a statement.
Jonathan H. Adler, a law professor at Case Western Reserve University and one of the architects of the new challenge, said the administration's approach may be good policy, but is contrary to the plain terms of the law.
''The Supreme Court has the opportunity to reaffirm the principle that the law is what Congress enacts, not what the administration or others wish Congress had enacted with the benefit of hindsight,'' Mr. Adler said. ''Granting tax credits to those who need help purchasing health insurance may be a good idea, and may have bipartisan support, but the I.R.S. lacks the authority to authorize such tax credits where Congress failed to do so.''
The case the Supreme Court agreed to hear comes from Virginia. It was brought by four people who said they did not want to be subject to the law's requirement that they buy insurance or pay a penalty. If it was not for the subsidies, they said, they would have been eligible for a hardship exemption.
In July, the United States Court of Appeals for the Fourth Circuit, in Richmond, Va., ruled against the challengers.
Judge Roger L. Gregory, writing for a three-judge panel of the court, said the contested phrase was ''ambiguous and subject to multiple interpretations.'' That meant, he said, that the I.R.S.'s interpretation was entitled to deference.
That same day, a divided three-judge panel of the United States Court of Appeals for the District of Columbia Circuit ruled the other way, agreeing with the challengers that only people in states that run their own exchanges are eligible for subsidies.
''We reach this conclusion, frankly, with reluctance,'' Judge Thomas B. Griffith wrote for the majority. ''Our ruling will likely have significant consequences both for the millions of individuals receiving tax credits through federal exchanges and for health insurance markets more broadly. But, high as those stakes are, the principle of legislative supremacy that guides us is higher still.''
In dissent, Judge Harry T. Edwards said the case was a ''not-so-veiled attempt to gut'' the health care law.
The Supreme Court often steps in when federal appeals courts have disagreed. But the split between the two courts was wiped out in September when the full District of Columbia Circuit vacated the July ruling and set the case for argument in December.
The challengers urged the Supreme Court to intercede anyway, saying that the sums involved are huge and that individuals, employers, insurers and states need a prompt and definitive resolution.
It takes only four votes to add a case to the Supreme Court's docket. They may have come from the four members of the court who were ready in 2012 to strike down the Affordable Care Act: Justices Antonin Scalia, Anthony M. Kennedy, Clarence Thomas and Samuel A. Alito Jr. Once again, it seems, the fate of the law may rest with Chief Justice John G. Roberts Jr.
As is the Supreme Court's custom, its one-sentence order did not disclose the justices' votes and gave no reason for the decision to hear the case, which came just before the health care law's open enrollment period is set to start next week.
Mr. Earnest, the White House press secretary, said the court's move has not, for now at least, altered the status quo.
''American families who have already enrolled, or are planning to sign up during the open enrollment period beginning on Nov. 15, should know that nothing has changed,'' he said. ''Tax credits and affordable coverage remain available.''
The question now is whether six words in the law contain the seeds of its destruction.
URL: http://www.nytimes.com/2014/11/08/us/politics/supreme-court-to-hear-new-challenge-to-health-law.html
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November 4, 2014 Tuesday
Why One Insurer Sees a Growing Market for Small-Business Health Insurance
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1041 words
HIGHLIGHT: Health Care Service Corporation sees an opportunity to attract small businesses that have not previously offered health insurance.
In an article The Times has just published, Reed Abelson surveys how small businesses are reacting to the Affordable Care Act. She found that some businesses are dropping coverage, and most are avoiding the government-run health insurance exchanges set up for small businesses. But Ms. Abelson encountered one insurance company that hoped to do a brisk business in the small-group market next year.
Health Care Service Corporation is introducing a private insurance exchange for businesses with up to 50 employees. It is known as Blue Directions for Small Business and will be available for 2015 in the five states where the company offers Blue Cross and Blue Shield insurance: Illinois, Montana, New Mexico, Oklahoma and Texas.
Private exchanges have grown increasingly popular with business owners because they're typically structured as a defined-contribution plan, rather than a defined-benefit plan. In a defined-contribution plan, a company specifies how much it will pay for insurance, and employees can use that money to choose among several health plans, paying more out of their own pockets if they choose more expensive options. Some see it as a way to help businesses insulate themselves from sharp increases in health care costs.
With Blue Directions for Small Business, a company can offer its employees six of the 40 or so small group plans that the Health Care Service Corporation offers in each market. Along with helping businesses control costs, the company is hoping to attract small businesses that previously have not offered their employees health insurance. "Eighty percent of groups under 10 people don't offer coverage," said Rick Allegretti, who runs the insurer's exchange business. "In the 10 to 50 market, about 60 percent of the employers do not offer coverage. In our five states, that's about 5 million employees who are not covered under a group plan."
Blue Directions, Mr. Allegretti said, takes inspiration from an obscure provision of the Affordable Care Act regulations that require insurers to make coverage available to any individual or small group that wants it. Normally, insurance companies will not cover a small group unless a majority of its members are willing to enroll and unless the employer contributes at least half of the premium cost. These minimum requirements act as a hedge against healthier employees refusing insurance and concentrating less healthy employees in the insured group - what's known in the industry as adverse selection. But under the new law's regulations, insurers must waive those minimum requirements for businesses that enroll between Nov. 15 and Dec. 15 every year, for coverage beginning at the start of the following year.
Those minimum requirements have long been seen as an obstacle blocking many small businesses from obtaining group coverage. "Our research suggests that 50 percent of businesses don't offer health insurance today, and the primary reason is that they can't meet the minimum contribution requirements," said Rick Lindquist, the president of Zane Benefits, which offers a controversial plan that lets businesses replace group coverage with subsidized individual insurance.
The Health Care Service Corporation, Mr. Allegretti said, is using Blue Directions to try to reach precisely those businesses that haven't been able to meet the contribution requirements. Because workers will be able to pay their health premiums with pretax wages, the employees may find the Blue Directions plans less expensive than buying in the individual market, even if their employers can't afford to contribute anything to the purchase.
But if workers, having reviewed all of the group options available, conclude that none of them are affordable, the Blue Directions exchange platform will help them figure out if they may be eligible for a subsidy to buy individual insurance and, if so, send them to the publicly run individual exchange to claim it. Here, the Health Care Service Corporation hopes that the presentation on the Blue Directions website will encourage employees to stay with Blue Cross, even though they are free to choose another carrier. The corporation has voluntarily extended the period in which it will waive the minimum participation and contribution thresholds until Feb. 15, to coincide with open enrollment in the individual market.
"Prior to A.C.A., adverse selection was a concern for us," Mr. Allegretti said. "That was an industry standard, in how we managed our small group block. Now that individuals have 90 days during the open period to choose us for their insurance, the adverse selection is mitigated," because it makes the company's risk pool in the individual market a bit healthier. In fact, Mr. Allegretti said the corporation is considering getting rid of the minimum requirements for Blue Directions altogether.
"Our goal is to keep that employee Blue in whatever plan or funding mechanism works best for them," he said. "Whether it's through the group or through the individual marketplace, whatever works best for them." Eventually, he said, as those employees rise in the company and outgrow subsidized individual coverage, they can transition seamlessly into a similar employer-sponsored group plan.
Which raises an interesting question: What happens if, in a company using Blue Directions, all of the lower paid employees end up on the individual market and all of the higher paid employees get group coverage. There is a provision in the Affordable Care Act that is intended to punish companies for using health plans to discriminate in favor of well-paid employees.
That provision is not being enforced as the Internal Revenue Service struggles to write rules implementing the nondiscrimination regulations, but could this be an issue for Blue Directions? Mr. Allegretti said the Health Care Service Corporation believed the plans were not discriminatory because the insurer offers basically the same plans in the individual exchange and the small-group market.
The corporation hopes to capture 1 to 3 percent of the working uninsured in the small group market in its five states - as many as 150,000 employees. "Some folks think that small group market is going to shrink," Mr. Allegretti said. "That's not our thinking here."
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December 17, 2013 Tuesday
Late Edition - Final
Archdiocese Wins Ruling on Contraception
BYLINE: By MOSI SECRET
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 26
LENGTH: 431 words
The Roman Catholic Archdiocese of New York was granted a federal injunction on Monday that blocks an Obama administration requirement to provide contraceptive care to employees at its nonprofit affiliates.
The ruling found that the regulation violated the religious freedom of the four nonprofit groups -- two high schools and two health care systems -- that are affiliated with the archdiocese but employ people of any faith. Under the Affordable Care Act, the nonprofit groups were required to provide the contraceptive coverage, authorize a third party to voluntarily pay for and provide the coverage, or pay steep fines.
The ruling, by Brian M. Cogan of Federal District Court in Brooklyn, found that forcing the groups to authorize a third party to provide contraceptive care still violated their religious beliefs even if they were not financially support contraception. Churches are already exempt from the mandate to provide contraceptive care.
As part of the Affordable Care Act, the federal government issued a rule that requires health plans to cover contraception without a co-pay. According to the American Civil Liberties Union, 88 cases have been filed challenging the rule as an infringement on religious liberty. Seventy-five of these cases are pending: 29 cases brought by nonprofit organizations, 43 cases brought by for-profit companies and three cases brought by both nonprofit and for-profit plaintiffs.
Judge Cogan's decision was the first permanent injunction against the regulations. A temporary injunction was issued in favor of a nonprofit Catholic organization in Pennsylvania.
The Archdiocese of New York, which sued along with the schools and hospitals, hailed the decision as a victory.
''The court has correctly cut through the artificial construct which essentially made faith-based organizations other than churches and other houses of worship second-class citizens with second-class First Amendment protections,'' Joseph Zwilling, a spokesman for the archdiocese, said in a statement.
The Justice Department, which argued the case for the Obama administration, can appeal the decision. Lawyers for the department declined to comment.
A lawyer for the American Civil Liberties Union, which filed an amicus brief in support of the government regulations, said the regulations did not pose an undue burden on the groups.
''While religious liberty is fundamental, it does not give employers the right to impose their beliefs on employees by denying contraceptive coverage and discriminating against their women employees,'' said Jennifer Lee, a lawyer with the group.
URL: http://www.nytimes.com/2013/12/17/nyregion/new-york-archdiocese-wins-ruling-on-contraception.html
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December 10, 2016 Saturday
Late Edition - Final
Data Do Not Support Critique of Health Act by Trump's Choice for Labor Secretary
BYLINE: By NOAM SCHEIBER and STEPHANIE STROM
SECTION: Section A; Column 0; National Desk; Pg. 16
LENGTH: 1197 words
Of all the policy positions taken by Andrew F. Puzder, the fast-food chief executive whom Donald J. Trump has chosen to be his secretary of labor, one he returns to with regularity is his passionate disdain for the Affordable Care Act and its effect on businesses and workers.
In the last few months, Mr. Puzder has spoken out multiple times -- in a speech before restaurant executives, on Fox Business, on the editorial page of The Wall Street Journal -- about what he calls a ''government-mandated restaurant recession.'' He says the law has led to rising health insurance premiums, ''reducing consumer spending, resulting in a reduction in restaurant visits.''
He has also argued that the act has given businesses an incentive to cut back on full-time workers to avoid the costs of providing them with insurance, as the act frequently requires.
The problem is that the available data largely disagree.
In his Wall Street Journal op-ed, Mr. Puzder leaned on a recent survey by the market research group Civic Science, which found that of those consumers spending more per month on health care than they were a year ago, 47 percent were spending less money patronizing fast food restaurants.
But industry numbers don't indicate this is having much of an effect. According to the National Restaurant Association, sales across the industry will be about $780 billion in 2016, up roughly 5 percent over the previous year. If you restrict the focus to fast food, sales are projected to be higher, too -- just under 6 percent, to about $223 billion, though the group notes that individual companies and regions may be struggling,
Neither does the data on restaurant industry employment suggest many ill effects. According to the Bureau of Labor Statistics, employment in the ''food services and drinking places'' industry is up nearly 200,000 this calendar year, and by nearly one million since Americans began buying health care through the Affordable Care Act.
Ben Spielberg of the Center for Budget and Policy Priorities, a liberal think tank in Washington, looked at the rise in premiums that a 27-year-old would pay for a common low-cost insurance plan under the health law. He compared that with employment in food services and drinking establishments over the same period.
The analysis looked at the 33 states in which data on both was available and concluded that there was no correlation between employment growth in the industry and premiums. States where premiums increased more did not tend to have lower employment.
The study's finding may seem counterintuitive, but it is consistent with the experience of at least some large fast-food outlets. Todd Penegor, the chief executive of Wendy's, said in an interview on Friday that while health care and rent costs have eaten into consumers' budgets, his company added stores in 2016 for the first time in years after previously scaling back stores. Mr. Penegor attributed the development to a successful new marketing program and a package of low-cost menu options.
To the extent that some restaurants are struggling, one explanation may be shifting consumer tastes rather than health care costs. A recent survey by the National Restaurant Association suggests that healthier offerings are gaining popularity, which could disadvantage fast-food outlets. ''Traffic has been incredibly strong for us,'' said Nic Jammet, co-founder and co-chief executive of the salad chain Sweetgreen. ''It's been a great year for us, not just with new store growth and customer acquisition but also our same-store sales have grown nicely, too.''
Even if health care costs are having an impact on certain restaurants, it's hard to directly point to the Affordable Care Act as the culprit. For one thing, fewer than 7 percent of Americans receive health coverage through the individual state marketplaces, where premiums have jumped, according to the Kaiser Family Foundation, which tracks insurance coverage. ''The fact that you had spikes in the premiums of about 7 percent of the people is not going to be determinant of those outcomes,'' said Jared Bernstein, a former economic adviser to Vice President Joseph R. Biden Jr.
Mr. Puzder's second complaint, that the law raises labor costs by mandating that employers cover full-time workers, appears more grounded in reality. It certainly would increase costs for employers who did not previously provide insurance coverage to full-time workers. ''We took a big hit initially from what we had paid previously,'' said Xavier Teixido, who owns three restaurants in Delaware and had provided full health coverage only to salaried managerial employees before the Affordable Care Act, though he offered a catastrophic illness plan to hourly workers.
Still, it does not appear that the potentially higher costs are motivating employers to reduce the size of their full-time work force, as Mr. Puzder feared. According to data analyzed by Nick Buffie of the left-leaning Center for Economic and Policy Research, the percentage of people who are forced to work part-time even though they prefer to work full-time has fallen dramatically since the Affordable Care Act was enacted. Perhaps more important, worker advocates say, even if the health law raised costs for business, considering only these costs leaves the analysis incomplete. The cost to businesses in the restaurant industry must be balanced against the benefits to workers, which have been significant in many cases.
''The restaurant industry has historically represented one of the largest segments with workers without health coverage,'' said Paul Sonn, general counsel at the National Employment Law Project, which advocates on behalf of low-wage workers. ''The A.C.A. has had a huge impact expanding access to low-cost and in many cases zero-cost coverage for restaurant workers.''
A question for Mr. Puzder, who has declined requests to comment since he was chosen for the post, is whether his view of labor -- and national policy -- will be overly shaped by his experience within one corner of one industry.
''We see different goals between a business owner trying to hold down costs and a national policy maker who ought to be focused on making sure that the benefits of growth are fairly and broadly shared,'' said Mr. Bernstein. ''For a guy like Puzder, suppressing labor costs is a good day at work. For the labor secretary, that's not the goal.''
Lawrence H. Summers, the former treasury secretary under President Bill Clinton and an economic adviser to President Obama, argues that one key to policy making is to avoid the fallacy of composition, in which what hurts or helps one actor does not necessarily produce the same effect when everyone does it. ''If one firm raises wages, that firm may be less competitive,'' he said. ''But if wages are raised at all firms, spending power may rise, and that may stimulate the economy.''
Mr. Summers added: ''This isn't a left-wing truth or a right-wing truth. You can't calculate all the effects of a policy just by generalizing from the experience of a business.''
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URL: http://www.nytimes.com/2016/12/09/business/andrew-puzder-critique-obamacare-data-donald-trump.html
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GRAPHIC: PHOTO: A Sweetgreen outlet in Berkeley, Calif., a salad chain where business was said by its co-founder to be ''incredibly strong.'' (PHOTOGRAPH BY JASON HENRY FOR THE NEW YORK TIMES)
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March 6, 2017 Monday
Late Edition - Final
Patience Gone, Koch-Backed Groups Will Pressure G.O.P. on Health Repeal
BYLINE: By JEREMY W. PETERS
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 1134 words
WASHINGTON -- Saying their patience is at an end, conservative activist groups backed by the billionaire Koch brothers and other powerful interests on the right are mobilizing to pressure Republicans to fulfill their promise to swiftly repeal the Affordable Care Act.
Their message is blunt and unforgiving, with the goal of reawakening some of the most extensive conservative grass-roots networks in the country. It is a reminder that even as Republicans control both the White House and Congress for the first time in a decade, the party's activist wing remains restless and will not go along passively for the sake of party unity.
With angry constituents storming town hall-style meetings across the country and demanding that Congress not repeal the law, these new campaigns are a sign of a growing concern on the right that lawmakers might buckle to the pressure.
''We've been patient this year, but it is past time to act and to act decisively,'' said Tim Phillips, the president of Americans for Prosperity, which is coordinating the push with other groups across the Kochs' political network. ''Our network has spent more money, more time and more years fighting Obamacare than anything else. And now with the finish line in sight, we cannot allow some folks to pull up and give up.''
The new mantra could be summed up as repeal, replace or revolt. Beyond the Koch network, other well-financed conservative groups like the Club for Growth and FreedomWorks are also increasing the pressure. All together, the new campaigns will involve advertising, rallies, phone calls to the Capitol switchboard and efforts to confront lawmakers in their offices with documentation of their own words about the need for repeal.
The Koch groups are calling their campaign ''You Promised,'' and are prepared to spend heavily, they said.
The initial phase, which will cost in the low six figures, will include a nationwide digital advertising campaign featuring testimonials from people who say they were harmed by the Affordable Care Act. On Tuesday, the groups will kick off the effort with a rally near the Capitol, from which they will dispatch activists to congressional offices. Beyond that, Americans for Prosperity said it was prepared to bring ''significant resources'' to bear as needed.
FreedomWorks, which is planning a rally in Washington on March 15 to inaugurate its ''month of action'' on the Affordable Care Act, is sending its activists to Capitol Hill armed with sheafs of paper with quotes from Republicans who have called for repeal. The plan is to track down those Republicans and make them face their own words.
''I think that the only way we get members of Congress to stay the course on this is with constituent pressure,'' said Noah Wall, the national director of campaigns for FreedomWorks. If that does not work at first, he added, ''I'm going to fill their offices with really angry constituents, and they're going to listen.
''And if they don't,'' he continued, ''I'm going to go back into their district and fill their district offices with angry constituents. And we'll do this again and again.''
The sudden caution of the Republican Party leadership, as it grapples with the enormously complicated challenge of replacing the Affordable Care Act, has baffled conservatives who have been fighting the health law for years. In the House, Republicans have voted dozens of times to dismantle the law, and it has been a primary issue in congressional races since 2010. Repealing the law, many conservative lawmakers believe, is the one clear mandate they have from voters.
''The reality is, this is existential for Republicans,'' said David McIntosh, the president of the Club for Growth, which has been sending emails regularly to its 100,000 members warning that Republicans could be stalling the repeal indefinitely. The group plans to directly target party leaders like Mitch McConnell, the Senate majority leader, and Paul D. Ryan, the House speaker, in a new phase of the campaign.
''If they don't repeal Obamacare and replace it,'' Mr. McIntosh added, ''I don't think they'll stay in the majority in the next election.''
Implicit in the repeal push is a threat that conservative groups have always wielded over the party when they feel it is not being true to its convictions: primary challenges.
And this early rift between the party's activist wing and its leadership in Washington could be a taste of what Republicans can expect now that they control the government entirely and are no longer able to blame Democrats for blocking their agenda. After making bold promises over the past few years on issues like overhauling expensive government programs, rewriting the tax code and defunding Planned Parenthood, Republicans face voter demands to follow through.
Republicans remain unable to agree on a health care plan that satisfies both moderates and hard-liners. As President Trump himself acknowledged last week when he tried to explain the delay -- ''Nobody knew that health care could be so complicated,'' he said -- it is no easy task to pass a measure that could leave millions uninsured. And polls now show American's attitudes toward the law are improving as they worry about what could happen if it is suddenly jettisoned.
Democrats, who have been cramming town hall-style meetings to implore Republican lawmakers not to take apart the health law, seem content to let their opponents fight it out in the hope that the divisions will lead to an impasse.
''Their rhetoric that has enabled them to stir up the far right is in collision with the truth,'' said Thomas E. Perez, the chairman of the Democratic National Committee.
The repeal effort by the conservative groups is intended to sway members of Congress who may be hesitating because of public pressure back home. That pressure, conservatives said, is no reason to renege.
''This issue has been litigated in four federal elections, and the result has been historic Republican majorities in Congress,'' Mr. Phillips of Americans for Prosperity said. ''That's why there is no sympathy when some Republicans talk about contentious town halls or a few hundred calls into their office.''
Americans for Prosperity, which has spent tens of millions of dollars in advertising opposing the Affordable Care Act, is bringing back some of the subjects of its initial ads -- ordinary people who spoke about the problems with ''government-run medicine'' -- for its new push. And it is arming activists with supporting evidence -- it found, for instance, that 98 percent of Republicans in the Senate, or 51 of the 52, had voted at one point to repeal the law.
''Congressional Republicans have promised an Obamacare repeal in unequivocal terms,'' Mr. Phillips said. ''It's time for them to keep their promise.''
URL: http://www.nytimes.com/2017/03/05/us/politics/koch-brothers-affordable-care-act.html
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November 1, 2015 Sunday
Late Edition - Final
State Policies Stand Out in Second Year of Affordable Care Act
BYLINE: By QUOCTRUNG BUI and MARGOT SANGER-KATZ
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 524 words
Two years into the Affordable Care Act, clear regional patterns are emerging about who has health insurance in America and who still doesn't.
The remaining uninsured are primarily in the South and the Southwest. They tend to be poor. They tend to live in Republican-leaning states. The rates of people without insurance in the Northeast and the upper Midwest have fallen into the single digits since the health law's main provisions kicked in. But in many parts of the country, obtaining health insurance is still a problem for many Americans.
These trends emerged in an analysis done with the help of two organizations that are closely monitoring the progress of the health law. Last year, we used similar data to show the substantial effects the Affordable Care Act had on reducing the number of Americans without health insurance. This year, the change is a lot less drastic. In some places, the declines have been more modest. In a few -- like Mississippi -- things appear to have gotten worse, with fewer people having health insurance this year.
''This year it's more of a state-specific story,'' said Ed Coleman, the director of data and analytics at Enroll America, an organization devoted to signing uninsured people up for insurance. Enroll America worked with the data firm Civis Analytics to produce the numbers in our map.
''There was a pronounced drop pretty much everywhere last year, and we don't see that pattern again this time around,'' Mr. Coleman added.
Medicaid expansion continues to be a huge predictor of how many people remain uninsured in a given state. We've outlined the states that expanded Medicaid in black to make them easier to see. But we almost don't have to, because many of the state lines are so clear from the uninsured rates alone. Look at the difference between Missouri and Illinois, for example.
Politics matters. Though several states with Republican leadership have expanded their Medicaid programs, many have not. Over all, Republican-leaning states continue to have more uninsured people than Democratic-leaning ones. But they also tended to have many more uninsured people at the start.
The data used to make this map are based on a survey and tools often used by political campaigns to target likely voters. That strategy allows us to show more detail than is available using more conventional surveys, but they also use different assumptions from those used in more conventional polling.
Some of the changes between last year's map and this year's may reflect refinements of the model more than major shifts in the level of the uninsured. In a few states, Enroll America's 2014 estimates differed from the 2014 census by more than a few percentage points. The states with these errors were those that had large rural, Hispanic or Native American populations: Alaska, Arizona, New Mexico and Texas, for example. On this year's map, it looks as if New Mexico's uninsured rate has gone back up, but that might just be a correction from an incorrect 2014 estimate. In most states, however, Enroll America has confidence in its estimates for all three years and thinks the shifts are real.
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GRAPHIC: MAPS: Who Still Doesn't Have Health Insurance: They tend to live in the South, and they tend to be poor. (Source: Enroll America)
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(In Practice)
October 1, 2013 Tuesday
Employees Without Health Care Coverage Looking to Exchanges
BYLINE: Dan Frosch
SECTION: US
LENGTH: 423 words
HIGHLIGHT: In Colorado, some consumers who have jobs but no health care coverage are looking to the exchanges for options.
AURORA, Colo. - Angela Graham, 51, has not had health insurance for years, and is not covered by her job conducting telephone surveys.
"It's something I'm definitely interested in," Ms. Graham said after picking up an informational packet on Colorado's new health care exchange, which opened on Tuesday along with others across the nation as part of the federal Affordable Care Act. "I don't go to the doctor these days. I just pray. That's the honest to god truth."
Ms. Graham was among a group of curious people at the Aurora Public Library, outside Denver, who stopped by a table set up by the Aurora Mental Health Center. It had stationed experts - known as "navigators" - there to tell people about the new health care coverage options available under the law. Ms. Graham said she had never heard anything about the exchange before walking into the library on Tuesday and she planned on checking with her employer to see if she was eligible.
Jesse Lopez, who was helping coordinate enrollment for the group, said he had been answering an array of questions, namely from people wondering if they qualified for the exchange through their employers.
"We're trying to let people know that we're up and running and de-escalating any frustration they may have," he said. "It's a new program, and it's somewhat of an emotional debate for folks. There is such a wide array of information out there so the concern for us is that the accurate information hasn't always been going out."
Craig Messinger, a retired state highway maintenance worker, said he was also strongly considering enrolling.
Mr. Messinger, 60, who is on disability because of a spinal condition, said he paid a nearly $500 a month premium for a Blue Cross Blue Shield health plan, money provided by his state retirement pension. It seemed an exorbitant amount, he said, considering he only collected an additional $1,400 a month in disability. And that didn't include payments for prescription drugs or other health care needs.
"I've been waiting for this to kick in. Things have been incredibly tight," he said, as he perused a packet on enrollment. "I'm needing to do some quick research to try and figure out which plan is going to work best for me so I can bring down my insurance cost."
Health Insurers Report High Volume of Queries on Health Care Coverage
Health Care Coverage Business Is Bustling at New York City Hospital
At a Miami Health Center, Told to Come Back Another Day
For Many, Personal Service Is More Helpful Than Web Site
Polls in Overtime on Affordable Care Act
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June 5, 2015 Friday
Late Edition - Final
Barely Meeting a Law It Hoped to Transcend
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1492 words
BURLINGTON, Vt. -- Just a few years ago, lawmakers in this left-leaning state viewed President Obama's Affordable Care Act as little more than a pit stop on the road to a far more ambitious goal: single-payer, universal health care for all residents.
Then things unraveled. The online insurance marketplace that Vermont built to enroll people in private coverage under the law had extensive technical failures. The problems soured public and legislative enthusiasm for sweeping health care changes just as Gov. Peter Shumlin needed to build support for his complex single-payer plan. Finally, Mr. Shumlin, a Democrat, shelved the plan in December, citing the high cost to taxpayers. He called the decision ''the greatest disappointment of my political life.''
As the United States Supreme Court prepares to rule in a case that could gut a major element of the Affordable Care Act -- federal subsidies for low- and middle-income people -- Vermont should have little to worry about. Only states that use the federally run insurance marketplace stand to lose subsidies if the court rules against the Obama administration, and Vermont is among the 14 states that fully run their own.
But even though its residents' subsidies appear safe for now, Vermont stands as a cautionary tale. Despite an eventual cost of up to $200 million in federal funds, its online marketplace, or exchange, is still not fully functional, while disgust with the system is running deep among residents and lawmakers alike.
Meanwhile, the hopes for a single-payer system, once tantalizingly close, may be lost for years. Under such a system, the government operates one health insurance plan for all residents, covering their medical costs instead of having private insurers do it.
''It's just been a spectacular crash, really,'' said State Representative Chris Pearson, a member of Vermont's Progressive Party. ''We've gone from this vision of being the first state to achieve universal health care, to limping along and struggling to comply with the Affordable Care Act.''
The bitterness stems partly from the fact that Vermont had some of the biggest elements of the Affordable Care Act in place long before it took effect. Health insurance companies here already could not refuse to cover people, or charge them more, if they had pre-existing medical conditions. The state also already had more generous Medicaid eligibility rules than most, and programs that helped lower-income people pay for private insurance, which made it less expensive for many than the new exchange plans.
To many Vermonters, the new federal law complicated a state system that had already provided good coverage and muddied the route to an even better model.
''This law, by preserving the private insurance system and treating health care as a commodity, made us do things that Vermont otherwise wouldn't have done,'' said James Haslam, the executive director of the Vermont Workers Center, a grass-roots group that has made universal, government-financed health care its central cause.
To strengthen support for such a system, the workers center is dispatching volunteers like Alissa Carberry, 24, to talk about their disappointment with the Affordable Care Act and why the state should not give up on its single-payer dream.
Ms. Carberry, a child care worker with Type 1 diabetes who earns $30,000 a year, said the insurance that her employer provided last year, from Vermont Health Connect, had a $1,900 deductible. Even after she met the deductible, she said, she still had to pay 40 percent of the cost of supplies like an insulin pump. She dropped the plan this year and switched to her partner's insurance, which is less expensive but still onerous.
''Let's continue to work for something better,'' Ms. Carberry said.
Under the single-payer law that the Vermont Legislature passed in 2011, the state was to seek a waiver in 2017 to trade its insurance exchange for the government-run system. Most of its 625,000 residents would be eligible for a uniform package of benefits under that system, which would be financed with a mix of state and federal funds.
But Mr. Shumlin and his advisers concluded the plan would require ''enormous'' new taxes, including an 11.5 percent payroll tax on all Vermont businesses and a sliding-scale income tax of up to 9.5 percent. In all, he said when he announced that he was shelving it, the plan would require about $2.5 billion in additional revenue in its first year, in a state that raises only about $2.7 billion in taxes annually.
Many Vermont health care advocates say support for the governor's plan was also seriously eroded by dysfunction in the state online insurance marketplace. Problems with that exchange had ''hurt, there's no doubt,'' public confidence in the effort to achieve single-payer universal coverage, Mr. Haslam said.
Other state-based exchanges have experienced as much or more turmoil: Oregon and Nevada essentially shut down their marketplaces last year, requiring residents who want subsidized insurance to enroll instead through the federal marketplace, HealthCare.gov. Hawaii is also planning to switch to the federal exchange this fall, at least temporarily, after running out of money. Massachusetts was forced to rebuild its exchange last year after it failed to function, and has spent more than $250 million, mostly in federal funds, on it so far.
A number of state-based exchanges, after receiving a total of nearly $5 billion in federal establishment grants, are also encountering financial problems because they now must cover their own costs.
But Vermont, with its initial view of the Affordable Care Act as a bridge to a single-payer system, is in a singularly unhappy position.
''There's a backlash against all things health care reform because Vermont Health Connect has been such a bad experience,'' said Trinka Kerr, the chief health care advocate at Vermont Legal Aid, which gets several hundred calls a month from people who have encountered problems with the exchange, including billing errors and even delayed access to care. ''Sometimes they'll say, 'I'll just go without insurance,' and we try to convince them that's not a good plan. They don't like the way this is working and want to go back to the old way.''
Rob Muessel, a self-employed security consultant from Shelburne, is one of those people. He said he spent hours on the phone with Vermont Health Connect representatives over the past year, trying to resolve problems. Most recently, when his daughter got a job with benefits in March, he called the marketplace to get her taken off his plan. Six weeks passed before he got a call back from an exchange employee, who had to spend more than two hours helping him redo his entire application for what should have been a simple fix.
''That just blew my mind,'' said Mr. Muessel, 61. ''I think it's time to pull the plug, because it may just be an unending money pit.''
In a blistering report released in April, Douglas Hoffer, the state auditor, detailed a number of unresolved problems with Vermont Health Connect and said it would be ''prudent'' to develop a plan for ''an alternative model for running an exchange.''
Mr. Shumlin had set a deadline of May 31 for Optum, the second vendor hired to fix a problem that has prevented thousands of Vermonters from easily changing basic information in their account, such as if they have a baby, get married or move. Workers have had to process such changes by hand, costing the state extra money and creating a backlog of 10,000 change requests. On Monday, Mr. Shumlin announced that Optum had fixed the problem, allowing such changes to be made in a matter of minutes, although customers will not be able to do so without assistance until later this year.
Optum has a second deadline, in October, to automate the process by which exchange plans are renewed from year to year. In an interview, Lawrence Miller, the state's chief of health care reform, said the state was analyzing the costs of various alternatives, including switching to the federal marketplace, should the exchange still be broken in the fall.
Mr. Miller said he would prefer Vermont to be ''tucked away in a fully state-operated marketplace until we see exactly how the Supreme Court rules'' in the subsidies case. A great deal of uncertainty remains about whether people would be able to keep their subsidies if the state started relying on the federal marketplace.
Mr. Miller added that Vermont intends to remain a leader in health care reform, particularly with a plan to replace the traditional system of paying health care providers for each procedure with one that pays them based on outcomes, including under Medicaid and Medicare as well as private coverage.
Pointing out that Vermont's was not the only state-based exchange to still be struggling, he added, ''I talk to my colleagues elsewhere and, good God, this just wasn't set up for success.''
URL: http://www.nytimes.com/2015/06/05/us/in-vermont-frustrations-mount-over-affordable-care-act.html
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GRAPHIC: PHOTOS: Gov. Peter Shumlin announced in December that he was shelving a plan to create the nation's first single-payer health care system. (PHOTOGRAPH BY GLENN RUSSELL/THE BURLINGTON FREE PRESS, VIA ASSOCIATED PRESS)
Alissa Carberry, 24, a child care worker with Type 1 diabetes, said she had insurance with a $1,900 deductible and had to pay 40 percent of costs after that. (A12)
Trinka Kerr, chief health care advocate at Vermont Legal Aid, a Burlington based group that fields hundreds of calls per month from people having trouble with the state's insurance exchange. (PHOTOGRAPHS BY JACOB HANNAH FOR THE NEW YORK TIMES) (A15)
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(You're the Boss)
January 6, 2014 Monday
The Information We Still Need to Manage Our Health Care
BYLINE: PAUL DOWNS
SECTION: BUSINESS; smallbusiness
LENGTH: 1233 words
HIGHLIGHT: If insurance companies would tell us what our expenses really are, we could make better choices.
After writing eight posts on my search for health insurance, which generated more than 275 comment from readers, I was more than ready to move on. After all, I do have a day job - running my little factory - and I have other projects and problems to address. But my mind keeps returning to a scene I witnessed the week before Christmas.
I came into my office a little late one morning and found my bookkeeper sitting in front of her computer, tears streaming down her face. This stopped me cold - I had never, in 27 years as a boss, seen one of my employees weeping. Alarmed, I asked her what had happened, and she told me: "I need to make a decision about which insurance plan to choose, and I can't figure out how much a doctor's visit will cost - and that's what I need to know. I've been on the phone all morning with Independence Blue Cross, trying to get an answer. I've been on hold, I've talked to people, I called my doctor, and I can't get anyone to give me a number. I am so frustrated I just want to - I can't say it."
My bookkeeper, as I mentioned in my last post, elected to leave our company group and buy insurance through the individual exchange. She works two days a week, and so had missed my presentation on how Affordable Care Act-compliant policies work, and she hadn't read my account of how I had failed in my own quest to find out what I could expect to pay out-of-pocket if I signed up for a silver or bronze policy. A numbers-oriented person, she had set up a spreadsheet to evaluate whether a silver or bronze policy was a better choice for her, and she had hit the same wall I had hit - not enough information to make a good decision.
And that brings me to the point of this post. I have taken a very long journey, starting with the first call from my agent and ending with my final decision as to what insurance to buy for 2014. Over those weeks, I spent a huge amount of time digging through the information given to me and trying to identify the best course of action for my company and my people.
I have come to appreciate some of the features of the Affordable Care Act. It's a courageous effort to kick-start a real market in health insurance. But I have also arrived at a conclusion as to how it could fail, at least for me and my workers. I offer my opinion in this matter in the same spirit as the rest of my writings: as a benchmark for you to use in evaluating your own experiences and your own options. If nothing else, I hope that my writing gives you some sense of what to watch for as you try to buy insurance for your own company.
The Affordable Care Act tries to impose order on the opaque and confusing market for health insurance, mostly by mandating that policies conform to certain standards: the metallic levels. The silver- and bronze-level policies shift a large percentage of the cost of health care directly to the individual subscribers. This might work if health care consumers have access to pricing information, so that they can see what they are paying for. But this has not yet happened, at least not for me.
The problem is that my insurance company, Independence Blue Cross, has offered incomplete or misleading information every step of the way. I only found out what was available to me and my company through extraordinary effort. And even after turning up what should be a good set of choices, I can see trouble ahead. The insurance company does not communicate the information that I, as an ordinary subscriber, will need to manage my health spending.
And that's surprising, because I don't need to know all that much - primarily, the answer to one question: How much of my out-of-pocket spending for my family's health care has been applied toward my policy's deductible? For high deductible plans, like Silver and Bronze level policies, this is a critical piece of information. Its answer also reveals what prices Independence Blue Cross has negotiated with doctors and hospitals and, by implication, what doctors are charging for their services.
A simple monthly or yearly statement, covering my whole family, would answer this question. It doesn't seem like an impossibly difficult task to generate something like this - my banks and my credit card companies do it for me without my asking. I get a statement in the mail from them, and I can log in to a website and see a real-time account any time I want.
Most insurance companies have the resources to interact with their subscribers in any way they choose. But I'm not aware of any regular statement that my insurer mails out, other than the monthly bill I pay for my employees. And that bill just shows a list of group members and how much I owe.
The only other place I can look is on the insurer's website. Without going into detail, I have had great difficulty finding even the most basic information on this site. Important features are hidden or have no instructions. The FAQ directs me to parts of the site that don't exist. And even if I fight through all of that, I run into other obstacles. When I log in as a subscriber, I can see claims for myself and one of my sons but not for my wife or the two older boys.
And the site only shows information for a three-month period. The expense numbers the site does offer do not include what the insurer has paid on my behalf, nor how much of my deductible has been used. Instead, they show what the doctor billed the insurer - and I now know from my research that this is neither the amount that the insurance company actually pays nor the amount that will be applied against my deductibles.
All of which makes it impossible for me to manage the expense of my family's health care use. I can't tell how much of my deductible each family member has used or whether the amounts we paid to the doctor are correct. As a result, I may have a very hard time figuring out whether my choice of plans worked out this year, or what to do next year.
Why is information being hidden from me? Who benefits when I can't make reasonable financial decisions? Why does my insurer choose to interact with clients in a way that reduces them to tears of frustration? The company is ostensibly a non-profit, so presumably it isn't doing it just to pocket my money.
So, here's my question for all of you: Does your insurance company do any better? Are there any large operators out there that send out a comprehensible monthly statement, or make useful information available online? If none of the insurance companies are doing this, then I fear for the Affordable Care Act. People will get frustrated trying to manage the high out-of-pocket costs of silver and bronze policies, and they will blame the A.C.A. - even though, it looks to me as though it's really an insurance company problem.
And then on Friday morning, my new 2014 insurance cards for my family arrived from Independence Blue Cross. And they have me in the wrong plan - it appears that after all the work I have done, someone in the insurer's back office simply signed me up for the plan my agent recommended in October. Here we go again.
Paul Downs founded Paul Downs Cabinetmakers in 1986. It is based outside Philadelphia.
What the New Health Insurance Law Means for My Workers
An Owner Figures Out How to Save on His Health Insurance
What I Needed to Understand About Health Insurance
A Business Owner's First Brush With HealthCare.gov
A Small Business Starts to Navigate the Affordable Care Act
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March 6, 2017 Monday
Late Edition - Final
'Really Sick and Really Scared' Voters Worry Congress
BYLINE: By JENNIFER STEINHAUER
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 1101 words
WASHINGTON -- Senator Shelley Moore Capito, Republican of West Virginia, has voted more than 50 times in Congress to repeal the Affordable Care Act. She plans to do it again this spring. But talking with voters in her impoverished state, which has a high rate of drug addiction, obesity and poor health, has given Ms. Capito a new sense of caution.
''I met a woman the other day with a terrible illness,'' she said. ''She is really sick and really scared.''
Ms. Capito and other Republican lawmakers, particularly in the Senate, increasingly see a need to tread carefully, or even alter course, as party leaders vow to quickly repeal and replace the health care law. That unease is all but certain to have an enormous impact as House and Senate Republicans begin to publicly draft a plan this month.
Animated by full control in Washington, Republicans have chosen a partisan route to remaking the law, in which 218 votes in the House and a mere 50 in the Senate are needed to repeal and replace it. While much of the focus has been on the potential for hard-line conservatives to act as spoilers with their opposition to anything but a bare-bones replacement, there is increased wariness among Republican senators who have the opposite concerns.
''Once low-income people are receiving good health care for the first time, it becomes very difficult for a member of Congress to take that assistance away from them,'' said Senator Susan Collins, Republican of Maine. ''To deprive them of that health care is something that now makes a lot of people in my party uncomfortable.'' She has co-sponsored a replacement plan that would let states keep many of the law's components now under fire from House Republicans.
President Trump has heightened the stakes, at times insisting that lawmakers replace the law immediately while repeatedly saying that no one should lose insurance coverage under a replacement plan. Patients with chronic illnesses, drug addicts, rural hospital executives and expectant mothers -- many of whom voted for Mr. Trump -- have made it clear that they will not support any plan that deprives them of what they now have, even if they dislike its origins in the Obama administration.
''Voters may not know how they got their health care,'' said Senator Joe Manchin III, Democrat of West Virginia, who has long endorsed making changes to the law, ''but they sure will know who took it away.''
Republicans hope to send a new health care measure to the president's desk this spring, but vast chasms have been exposed between the most conservative members and other Republicans, and the White House has yet to provide clear guidance by endorsing specific provisions.
While promising to maintain the most attractive parts of the law, like forcing insurers to offer coverage for patients with pre-existing conditions, congressional Republicans have long set a central goal of ensuring ''access'' to care -- not guaranteeing care -- while shoring up the insurance marketplace.
But Mr. Trump upended that message when he said in January that any Republican plan would ''have insurance for everybody,'' a notion he has repeated. Lawmakers have taken notice, sometimes echoing his language.
''I think the no-gaps-in-coverage part is important,'' Ms. Capito said, noting that expanded coverage was the Obama administration's main focus. ''For every push, there is a pull.''
Mr. Trump has further complicated matters by insisting that any plan replace the law as soon as it is repealed; Republicans had hoped to put the replacement off.
In addition, the Affordable Care Act's Medicaid expansion -- which has extended coverage to roughly half of the 20 million people who have gained insurance under the law -- has been embraced by a majority of governors. Many of them, including Republicans, have said in meetings with both lawmakers and Mr. Trump that they want to continue that program.
''While I clearly have concerns about the expansion's long-term costs,'' Senator Lisa Murkowski, Republican of Alaska, said in an address to the State Legislature last month, ''it has strengthened our Native health system and reduced the number of uninsured that are coming into our emergency rooms.
''So as long as this Legislature wants to keep the expansion,'' she continued, ''Alaska should have the option. So I will not vote to repeal it.''
Even senators in states with no Medicaid expansion concede that the law is baked into the culture, sometimes in ways their constituents are not fully aware of, and in ways they themselves have fought for. Most notably, the Affordable Care Act has increased money and access to programs for Americans with mental illness and drug addiction, especially in states, like Ohio, that accepted the Medicaid expansion and have a large population of opioid drug abusers.
''While we work to reform Medicaid as part of replacing the A.C.A.,'' said Senator Rob Portman, Republican of Ohio, who has made the opioid crisis one of his chief concerns, ''close attention must be paid to the growing opioid epidemic and the need for drug treatment and recovery.''
Many states that overwhelmingly supported Mr. Trump's presidential campaign are some of the biggest beneficiaries of the health care law, even if their governors chose not to accept the Medicaid expansion. In some cases, those states still found ways to use the law to offer services like cancer screenings. Other, less-celebrated programs have been a boon, like one that permitted states to create medical ''homes'' for patients with multiple chronic conditions.
''One of the things that is underappreciated is that there are lots of little things in the A.C.A. that a bunch of red states took advantage of, even if they didn't expand,'' said Richard Frank, a Harvard Medical School professor who worked at the Department of Health and Human Services in the Obama administration. He cited programs for disabled people in Louisiana and Missouri, and guidelines that allowed states to redefine poverty lines to get more residents covered by Medicaid even without the federal expansion.
''Those turned out to be very useful for their costly populations,'' Dr. Frank said. ''It's unclear, if they repeal, if Congress would take those away.''
As residents become aware that benefits they have received were part of the health law and may go away, so do their elected representatives.
''In some ways it has been a health care education process for everyone,'' Mr. Manchin said. ''Even for people here.''
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/03/05/us/politics/affordable-care-act-health-law-republicans.html
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GRAPHIC: PHOTOS: People signing up for health insurance through the Affordable Care Act at the Mall of the Americas in Miami in November. (PHOTOGRAPH BY ANGEL VALENTIN FOR THE NEW YORK TIMES)
Senators Lisa Murkowski, left, and Susan Collins, center, both Republicans, have acknowledged some benefits of the law. (PHOTOGRAPH BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES)
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June 24, 2012 Sunday
Late Edition - Final
Money or Your Life
BYLINE: By THERESA BROWN.
Theresa Brown is an oncology nurse and the author of ''Critical Care: A New Nurse Faces Death, Life, and Everything in Between.''
SECTION: Section SR; Column 0; Sunday Review Desk; BEDSIDE; Pg. 9
LENGTH: 865 words
He was one of those salt-of-the-earth guys from the rural part of Pennsylvania. Middle-aged, married with adult kids, he'd worked his whole life running his own small business, a local restaurant that he jokingly called a bordello. His wife worked, too, and she had health insurance, but he wasn't on her policy. Maybe he couldn't afford it, or he was saving money by playing the odds. After all, he'd always been healthy. And then one day he had leukemia.
I was his nurse, and he surprised me one afternoon by bringing up ''death panels.'' Usually I avoid having political conversations in the hospital, but he was preoccupied with something that wasn't real. I didn't want him worrying about a chimera when he was adjusting to a diagnosis of cancer and an inpatient hospital stay that would last six weeks or more.
I told him there was no such thing as death panels.
''Really?'' he said, in his raspy voice. ''Because I hoped there were.''
Since he lacked insurance, he feared treatment would bankrupt his family. Trading his life for their livelihood wasn't an exchange he could make. A death panel, he reasoned, would spare him that cruel choice.
This was not suicidal ideation, but the worries of a kind and caring man. Hospitals are filled with people like him, patients who will need thousands of dollars of medical care just to have a chance at staying alive. At the top of the list are those with a fatal cancer. But there are many other less obvious ones: a patient who got kidney failure from strep throat, a healthy 22-year-old who needed a stay in the intensive-care unit to survive the H1N1 virus, a flight attendant far from home and desperately short of breath because of a blood clot in the lungs.
As a result of the 1986 Emergency Medical Treatment and Labor Act, patients needing immediate care cannot be turned away from an emergency department because of an inability to pay. But who picks up the cost of that visit and any later care that's required? Either uninsured patients get huge bills from the hospital, or the rest of us pay for their care indirectly, through higher insurance premiums and increased out-of-pocket costs and deductibles.
The problem is, this robbing-Peter-to-pay-Paul system is quickly becoming economically unsustainable. The uninsured are not paying into the system up front, but one way or another the costs of their care are still being covered.
To address this cost-benefit disparity, the Affordable Care Act requires all Americans to buy health insurance -- the idea being that if most of us pay regular insurance premiums, then we as a nation will have enough money in the insurance pot to cover everyone needing care at any one time. Additionally, requirements for getting insurance will become more uniform, and costs will drop.
If the Affordable Care Act is overturned -- either legislatively or by the Supreme Court, which might announce a decision on its constitutionality this week -- the insured will continue to subsidize the uninsured. Costs of coverage and care will rise, in turn making insurance affordable for fewer and fewer people.
Critics of the Affordable Care Act argue that many Americans neither want nor need health insurance, and that it forces them to pay for coverage against their will. But just as the government collects taxes to pay police officers and firefighters, the individual mandate compels Americans to pay for a service they may not immediately want but could at any time desperately require.
Much of the debate has focused on the role of government in everyday life. I don't discount the value of that question, but my focus is on real needs. I treat patients with $20,000 chemotherapy injections or monthly doses of IV immunotherapy that cost $10,000 a bag. If they don't receive these drugs my patients will die, so to me, the most pressing issue here is compassion. Without change, the patients will resemble the man with leukemia, human beings without insurance terrified that their lives aren't worth what it will cost to save them, all because of a broken but fixable system.
Crowds at conservative rallies have, astoundingly, cheered the idea that uninsured people should, if they become ill or badly hurt, be left for dead. It's easy to imagine such a thing in the heat of a rhetorical moment. But the reality is, I hope, harder to embrace. Because reality means a real person -- you, me, someone we know -- condemned to a possibly preventable death because, for whatever reason, they don't have insurance.
My patient with leukemia is dead. He got the best care money could buy, but his disease only briefly went into remission and he went home on hospice care. Should he, because he did not buy insurance, have been denied this chance for a cure?
The Affordable Care Act is not the health care solution everyone wants, but when patients wish for death panels as a response to leukemia, something needs to be done, and soon. This plan would help any patient facing a tough diagnosis not view treatment as a choice between his money or his life.
This is the first article in Bedside, a new series about nursing and health care.
This is the first article in Bedside, a new series about nursing and health care.
URL: http://www.nytimes.com
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The New York Times Blogs
(Taking Note)
June 21, 2012 Thursday
Health Care Confusion
BYLINE: LAWRENCE DOWNES
SECTION: OPINION
LENGTH: 308 words
HIGHLIGHT: Far more money has gone into attacking the A.C.A. than defending it. Maybe it's not surprising that people neither understand it nor like it.
The Times's Abby Goodnough reported today that right-wing groups have spent $235 million on ads attacking President Obama's health-care law - and seem to have gotten their money's worth. People hate the law, they don't understand it, they think it's something that will hurt, oppress and bankrupt them - even when it won't.
People like Erika Losse, a part-time worker in her mid-30s with no health insurance, who pays out of pocket for care and would probably qualify for subsidies under the Affordable Care Act. She told Abby, "I'm positive I can't afford it." Actually, what she can't afford is insurance the ACA.
The article explains that spending on the other side has been minuscule - that there are very few ads sticking up for the law, and those that try to do so are lame.
"Did you know with your health insurance, you may now have some preventive benefits with no co-pays or out-of-pocket costs?" asks one ad from the Department of Health and Human Services.
Using such tentative, even-keeled language is the equivalent of pulling out a knife in a gunfight. The pro-health care side talks of "some preventive benefits" while the antagonists call Obamacare a socialist-rationing-Canadian scheme to destroy freedoms, bankrupt society and hasten early death. Wasn't that why Natasha Richardson died in a skiing accident - because it happened in CANADA?
The Supreme Court has yet to rule on the constitutionality of the law, which has been the signature domestic achievement of Mr. Obama's presidency. But opponents of health care reform have always seen this as two battles - for the opinions of judges and for the opinions of voters. It looks like they may already have won the second.
Shooting at Laws in Ads (Literally)
'Washington Doesn't Get Us'
Healthcare: What Might Have Been
Romney's Health Care Plan
No Comment Necessary: Gun Control and Genocide
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The New York Times
October 30, 2014 Thursday
Late Edition - Final
California's Proposition 45 Would Offer Public a Say on Health Insurance Rates
BYLINE: By IAN LOVETT; Adam Nagourney contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 794 words
LOS ANGELES -- A year after the federal Affordable Care Act took effect, California voters are now considering another major change to health care: a ballot measure that would give state officials the authority to veto health insurance rate increases for individual and small group plans.
Proposition 45 would hand broad new control of the individual health insurance market to the state insurance commissioner, who could reject rate increases deemed excessive. The measure is designed to keep costs down for consumers in a state where health care premiums have spiked in recent years, raising public ire.
But that was before the Affordable Care Act. Now, Covered California, the state's health care exchange, negotiates rates with insurers. And opponents of the ballot measure warned that it could undermine the early successes of Covered California, which enrolled more than 1.1 million people -- more than any other state -- in its first year.
With millions at stake for consumers and insurance companies, the campaign has become one of the most expensive in the state. Insurers in California -- primarily Kaiser Permanente, WellPoint and Blue Shield of California -- have poured more than $55 million into defeating the measure, more than 15 times what the supporters have raised.
Dave Jones, the insurance commissioner, who is running for re-election, said the huge sums that insurance companies had spent trying to discredit the measure and its supporters demonstrated the need for laws to stop them from raising rates at will.
''Even with the successful implementation of the Affordable Care Act, Californians are still facing double-digit rate hikes,'' Mr. Jones, a Democrat, said. ''Right now, health insurance rates are set behind closed doors. The public has absolutely no say. This proposition is about allowing the public to participate.''
Most states require approval by state regulators for at least some health care rate increases, according to a study by the Kaiser Family Foundation.
But Proposition 45 would go further than other states: Even after the commissioner approved a rate increase, members of the public could sue to stop it.
The insurance companies, all three of which have refused to speak publicly about the measure, are hardly the only opponents. Health care reform advocates, including the Democrats who dominate state politics here, remain split. Even some longtime supporters of more robust health insurance regulation have balked, saying that additional regulations could confuse consumers or drive insurers from the marketplace.
Unlike with auto or property insurance, most consumers can sign up for new health coverage only during the annual open-enrollment period that begins in November.
George Miller, a Democratic congressman and a co-author of the Affordable Care Act, said he worried the proposed rate approval system could slow the process for determining the annual rate, leaving consumers in the dark during open enrollment. He suggested waiting to see whether Covered California's negotiations with insurers kept rates down.
''To put this considerable amount of turmoil in the open enrollment process worries me,'' Mr. Miller said in a telephone interview.
Mr. Miller visited call centers after last year's start-up and listened to some of the conversations with potential Covered California customers. ''It didn't take much confusion before people would say, 'I'll call you back,' '' he said. ''My goal is to enroll every single possible person this time.''
Diana S. Dooley, a member of Covered California's board, said the exchange had been aggressively negotiating to keep premiums reasonable, which she worried might become more difficult if the commissioner could then reject rates. But she said the provision that would allow consumer groups and other interveners to sue over rates even after the commissioner had approved them was the most concerning part of the ballot measure.
''Someone who's a foe of the Affordable Care Act -- and goodness knows we've seen a few of them over the last year -- could go to court as a way to destabilize the program and delay approval of rates until after the open enrollment period,'' Ms. Dooley said.
The measure's sponsor, a group called Consumer Watchdog, backed a similar and successful ballot proposal in 1988, which brought rate approval to auto, home and business insurance. After California adopted it, rate approval soon spread across the country in those industries, and the policy has helped keep rates down, said Jamie Court, the president of Consumer Watchdog. He said Proposition 45 had the potential to do the same.
''If really tough regulation passes in California, it will spread to other states, and we will start to see tougher oversight more generally,'' Mr. Court said.
URL: http://www.nytimes.com/2014/10/30/us/californias-proposition-45-would-offer-public-a-say-on-health-insurance-rate-increases.html
LOAD-DATE: October 30, 2014
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Yes on Proposition 45 supporters rallied this month outside Blue Shield of California in El Segundo. The ballot measure would require health insurance companies to justify rate increases. (PHOTOGRAPH BY MONICA ALMEIDA/THE NEW YORK TIMES)
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Copyright 2014 The New York Times Company
414 of 1000 DOCUMENTS
The New York Times Blogs
(Opinionator)
July 3, 2013 Wednesday
Obama's Insurance Delay Won't Affect Many
BYLINE: EZEKIEL J. EMANUEL
SECTION: OPINION
LENGTH: 760 words
HIGHLIGHT: Reform is proceeding, despite the delay of a mandate for employers.
On Tuesday, the White House announced that it would delay for another year one provision of the 2010 health care reform act. Larger employers will now have until 2015 before they will have to provide insurance or face penalties. The administration's explanation is that it is listening to businesses' concerns about getting their coverage ready in time, and trying to be flexible. But what people are really concerned about is whether this will make a difference in health care coverage and the progress of reform.
The short answer is no.
The employer mandate was included in the Affordable Care Act - which I helped design as an adviser to the Obama administration - in order to ensure the continuation of employer-sponsored insurance after the creation of state-sponsored health care exchanges. We didn't want every employer to simply drop its coverage and send all its workers to the exchanges.
But complying is proving to be more difficult than expected for employers. The act requires businesses with more than 50 employees to provide coverage to their full-time workers or face a penalty of $2,000 per employee. A full-time worker is defined as someone who is paid for 30 or more hours of service a week or 130 hours a month. It sounds simple, but determining who should be counted turned out to be a nightmare.
Hours of service include paid vacation and sick time, as well as things like jury duty. And how do seasonal workers fit in, or people who work just one semester at an academic institution? Employers rightly complained about the complications, and the administration was right to listen.
Delaying enforcement of the mandate won't hurt the progress of health care reform because, the fact is, the requirement affects very few employers.
There are around six million employers in the United States. The vast majority - 96 percent - are small, employing fewer than 50 workers. Many don't offer health insurance. For instance, among employers with fewer than 10 workers, half don't offer insurance. But the employer mandate does not affect them, and they don't pay a penalty.
Only about 200,000 employers have more than 50 workers. And the vast majority of them - 94 percent or more, according to the Kaiser Family Foundation and Health Research and Educational Trust - already offer health insurance. Thus, fewer than an estimated 12,000 employers fail to offer health insurance and would be subject to the penalty. That means we're talking about only maybe 1 or 1.5 million workers.
Certainly, for these workers, having health insurance would be a great benefit. And covering more Americans was a central rationale for the Affordable Care Act.
But not having their employers provide insurance doesn't mean they have to wait much longer for coverage. In October, thanks to the Affordable Care Act, they will be able to buy insurance on the exchanges. They won't have to worry about having a pre-existing condition, and they will receive an income-based subsidy to help defray the costs.
It is also highly unlikely that the administration's announcement will encourage any of the other 94 percent of large employers to drop their health insurance. They provide it now with no mandate. No law requires General Electric or Verizon to provide its workers health insurance today. They do it because it makes business sense in terms of attracting and retaining good workers.
Perhaps, after the exchanges go into effect and prove themselves reliable, some employers will be tempted to drop their coverage. But by the time any of them can make the change, it will be 2015, and by then the penalty will be in place.
The employer mandate is overly complicated. Representatives in the House had what was probably a better idea: to make employers devote a certain percentage of their payroll to health insurance, instead of doing it by the number of full-time workers. That would have been a far simpler determination. It was one of those points that was supposed to be resolved in conference committee. But alas, the election of Scott Brown, the Massachusetts Republican, lost the Democrats their supermajority in the Senate, and we had to move forward with the version of the act that had already passed. The good ideas from the House never made it in.
But whatever the merits or demerits of the employer mandate, and despite the headlines this week, postponing the mandate's enforcement by one year isn't particularly noteworthy.
Million-Anecdote Baby
A Plan To Fix Cancer Care
Health Care's Good News
When Paying It Forward Pays Us Back
The Faulty Logic of the 'Math Wars'
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The New York Times
January 17, 2017 Tuesday 00:00 EST
Health Law Repeal Could Cost 18 Million Their Insurance, Study Finds
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 1419 words
HIGHLIGHT: The Congressional Budget Office said 18 million people would lose their insurance in the first year, with that number and costs rising over 10 years.
WASHINGTON - Eighteen million people could lose their insurance within a year and individual insurance premiums would shoot upward if Congress repealed major provisions of the Affordable Care Act while leaving other parts in place, the nonpartisan Congressional Budget Office said on Tuesday.
A report by the office sharply increases pressure on Republicans to come up with a comprehensive plan to replace the health care law. It is likely to doom the idea of voting to dismantle the 2010 health law almost immediately, with an effective date set sometime in the future while Congress works toward a replacement.
If nothing followed the gutting of President Obama's signature domestic achievement, the budget office said, 32 million people could lose their health insurance by 2026, and premiums in the individual insurance market could double. Senator Susan Collins, Republican of Maine, showed the unease of some in her party when she said that repealing the health care law and delaying a replacement could send insurance markets into "a death spiral."
She detected "a growing consensus among members of both the Senate and the House that we must fix Obamacare and provide reforms at nearly the same time that we repeal the law," she said on the Senate floor on Tuesday.
The new budget office report, issued after a weekend of protests against repeal, will only add to the headaches that President-elect Donald J. Trump and congressional Republicans face in their rush to take apart Mr. Obama's health law as they try to replace it with a health insurance law more to their liking.
Republicans cautioned that the report painted only part of the picture - the impact of a fast repeal without a Republican replacement. Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee, said the numbers represented "a one-sided hypothetical scenario."
"Today's report shows only part of the equation - a repeal of Obamacare without any transitional policies or reforms to address costs and empower patients," he said. "Republicans support repealing Obamacare and implementing step-by-step reforms so that Americans have access to affordable health care."
Congress last week approved a budget that clears the way for speedy action to repeal the health care law. The votes were 51 to 48 in the Senate and 227 to 198 in the House.
But Republicans have yet to agree on a replacement bill, and existing Republican plans, like one drafted by Representative Tom Price of Georgia, who was selected as Mr. Trump's secretary of health and human services, have yet to be scrutinized by the budget office. The office provides Congress with the official projections of legislative costs and impact that lawmakers use to formulate policy.
"No wonder President-elect Trump realizes that repeal without replace is the real disaster," said Senator Chuck Schumer of New York, the Democratic leader. "No wonder he has admonished the Congress not to do plain repeal."
Republicans now have two powerful reasons to "repeal and replace" together: They hope to protect about 20 million Americans who have gained coverage under the law. And they want a politically acceptable judgment from the Congressional Budget Office on the effects of their alternative.
Mr. Trump's statement last week that a replacement plan should go hand in hand with repeal efforts had already ignited a sense of urgency among Republicans on Capitol Hill. Over the weekend Mr. Trump said he was close to completing a plan to replace the Affordable Care Act with the goal of "insurance for everybody," but congressional aides said Tuesday that they had not seen an actual proposal.
Republican congressional leaders are trying to put together a plan that could pass muster with the Trump team and also win approval in the Senate under fast-track procedures that would neutralize the threat of a Democratic filibuster.
House Speaker Paul D. Ryan and Senator Mitch McConnell of Kentucky, the Republican leader, met last week with Mr. Price to hash out alternatives, and they have been in close contact with the relevant committee leaders and staff members to begin hammering out ideas that could come into relief at the end of the month, when Republicans have their annual policy retreat.
Stephen Miller, a former Senate press aide and the incoming senior White House adviser for policy, who has been particularly aggressive in presenting himself as the voice of Mr. Trump on all policy matters, has pushed the notion that a plan should move quickly and in tandem with a replacement measure, rather than in a series of smaller bills, congressional aides said.
The repeal legislation analyzed by the budget office would have eliminated tax penalties for people who go without insurance. It would also have eliminated spending for the expansion of Medicaid and subsidies that help lower-income people buy private insurance. But the bill preserved requirements for insurers to provide coverage, at standard rates, to any applicant, regardless of pre-existing medical conditions.
"Eliminating the mandate penalties and the subsidies while retaining the market reforms would destabilize the nongroup market, and the effect would worsen over time," the budget office said.
The office said the estimated increase of 32 million people without coverage by 2026 resulted from three changes: About 23 million fewer people would have coverage in the individual insurance market. Roughly 19 million fewer people would have Medicaid coverage. And there would be an increase in the number of people with employment-based insurance that would partially offset those losses.
The estimates by the budget office are generally consistent with projections by the Obama administration and by insurance companies.
In its report, the budget office said that repealing selected parts of the health care law - as specified in the earlier Republican bill - would have adverse effects on insurance markets.
In the first full year after the enactment of such a bill, the office said, premiums would be 20 percent to 25 percent higher than under current law.
Repealing the penalties that enforce the "individual mandate" would "both reduce the number of people purchasing health insurance and change the mix of people with insurance," as younger and healthier people with low health costs would be more likely to go without insurance, the budget office said.
The Republican bill would have eliminated the expansion of Medicaid eligibility and the subsidies for insurance purchased through Affordable Care Act marketplaces, after a transition period of about two years.
Those changes could have immediately increased the number of uninsured by 27 million, a number that would gradually increase to 32 million in 2026, the budget office said.
Without subsidies, the budget office said, enrollment in health plans would shrink, and the people who remained in the individual insurance market would be sicker, with higher average health costs. These trends, it said, would accelerate the exodus of insurers from the individual market and from the public marketplaces.
As a result, it said, about half of the nation's population would be living in areas that had no insurer participating in the individual market in the first year after the repeal of marketplace subsidies took effect. And by 2026, it estimated, about three-quarters of the population would be living in such areas.
While writing the Affordable Care Act in 2009 and 2010, lawmakers continually consulted the Congressional Budget Office to understand the possible effects on spending, revenue and insurance coverage. The current director of the budget office, Keith Hall, who signed the report issued on Tuesday, was selected and appointed by Republican leaders of Congress in 2015.
The latest report was requested by Mr. Schumer and two other Democrats, Senators Ron Wyden of Oregon and Patty Murray of Washington.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
Jennifer Steinhauer and Thomas Kaplan contributed reporting.
PHOTOS: Senator Susan Collins (PHOTOGRAPH BY AL DRAGO/THE NEW YORK TIMES) (A1); Many customers of Sunshine Health and Life Advisors in Miami would be affected by changes to the Affordable Care Act. (PHOTOGRAPH BY ANGEL VALENTIN FOR THE NEW YORK TIMES) (A16)
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The New York Times
March 8, 2017 Wednesday
Late Edition - Final
Analysts Say Millions Risk Losing Coverage in G.O.P. Health Plan
BYLINE: By ABBY GOODNOUGH and REED ABELSON; Abby Goodnough reported from Washington, and Reed Abelson from New York.
SECTION: Section A; Column 0; National Desk; Pg. 15
LENGTH: 1302 words
WASHINGTON -- Millions of people who get private health coverage through the Affordable Care Act would be at risk of losing it under the replacement legislation proposed by House Republicans, analysts said Tuesday, with Americans in their 50s and 60s especially likely to find coverage unaffordable.
Starting in 2020, the plan would do away with the current system of providing premium subsidies based on people's income and the cost of insurance where they live. Instead, it would provide tax credits of $2,000 to $4,000 per year based on their age.
But the credits would not cover nearly as much of the cost of premiums as the current subsidies do, at least for the type of comprehensive coverage that the Affordable Care Act requires, analysts said. For many people, that could mean the difference between keeping coverage under the new system and having to give it up.
''The central issue is the tax credits are not going to be sufficient,'' said Dr. J. Mario Molina, the chief executive of Molina Healthcare, an insurer that offers coverage through the Affordable Care Act marketplaces in California, Florida and several other states.
Martha Brawley of Monroe, N.C., said she voted for President Trump in the hope he could make insurance more affordable. But on Tuesday, Ms. Brawley, 55, was feeling increasingly nervous based on what she had heard about the new plan from television news reports. She pays about $260 per month for a Blue Cross plan and receives a subsidy of $724 per month to cover the rest of her premium. Under the House plan, she would receive $3,500 a year in tax credits -- $5,188 less than she gets under the Affordable Care Act.
''I'm scared, I'll tell you that right now, to think about not having insurance at my age,'' said Ms. Brawley, who underwent a liver biopsy on Monday after her doctor found that she has an autoimmune liver disease. ''If I didn't have insurance, these doctors wouldn't see me.''
The Congressional Budget Office has yet to release its official estimates of how many people would lose coverage under the proposal, but a report from Standard & Poor's estimated that two million to four million people would drop out of the individual insurance market, largely because people in their 50s and early 60s -- those too young to qualify for Medicare -- would face higher costs. Other analysts, including those at the left-leaning Brookings Institution, have estimated larger coverage losses.
While the tax credits in the Republican proposal are the most generous for older people -- $4,000 for a 60-year-old compared with $2,000 for a 25-year-old -- they end up covering less of an older person's costs. As soon as next year, the Republican plan would allow insurers to begin charging older individuals much more than younger individuals. Insurers are prohibited today from charging the older person more than three times as much as the youngest, but the Republican plan would allow them to charge five times as much. A 64-year-old could see annual premiums increase by almost 30 percent to $13,100 on average, according to the S.&P. analysis.
For people like Alan Lipsky, a self-employed consultant in Arden, N.C., the Republican plan could have a huge financial impact. Mr. Lipsky, who is 60 and whose wife is in her 50s, receives a tax credit of $2,097 a month for his family of four and pays $66 a month out of his own pocket. His family's total annual tax credit of $25,164 would be reduced to $11,500 under the new plan, covering less than half of the total cost of his current coverage.
''I don't think the Affordable Care Act is perfect,'' said Mr. Lipsky, whose family deductible is $12,000 per year, ''but at least for people like me it gives a baseline, and I'm worried I won't have that baseline anymore. What they're talking about is unaffordable for me.''
Not everyone would lose out. Some younger adults would probably benefit the most from age-based tax credits and proposed changes that would allow insurers to offer them less expensive policies, such as those with less generous coverage.
Joshua Yospyn, 40, a freelance photographer in Washington, earns slightly too much to receive a tax credit under the Affordable Care Act and pays about $374 a month for his BlueChoice H.M.O. plan. The Republican proposal would provide him with an age-based tax credit of $3,000 a year, which would cut his current premium costs by two-thirds, to $1,488 from $4,488.
Mr. Yospyn said he would love cheaper premiums but did not want to give up comprehensive coverage, his low deductible of $500 a year or the doctors he now sees. A physical this month, his first in several years, revealed that his cholesterol had risen sharply, leaving him ''freaked out,'' he said.
''I just want protection across the board,'' he said, referring to the kind of policy he preferred. ''It's what I'm used to.''
Other people likely to be hurt under the new plan are those in areas where the cost of coverage is high. Subsidies are now pegged to the cost of a plan within a specific market, but the tax credits in the Republican plan are the same whether you live in Alaska or Minnesota. Coverage tends to be most expensive in parts of the country where there are few hospitals or few insurers. ''When it comes to health insurance, high-cost areas tend to be rural areas,'' said Cynthia Cox, a researcher at the Kaiser Family Foundation, which recently did an analysis of how the tax credits compared with the subsidies now available.
The proposal would also eliminate another important element of the subsidies, the financial assistance available for low-income people with their out-of-pocket costs, such as deductibles and co-payments. While many of the plans now sold through the Affordable Care Act marketplaces have large deductibles, the cost-sharing reductions available protect lower-income people from medical bills that could otherwise run into the thousands of dollars. Analysts say the lack of out-of-pocket assistance is likely to make any plan much less attractive to low-income people.
Legislation could also fundamentally weaken the insurance market by doing away with the so-called individual mandate, which requires people to have coverage or pay a tax penalty. While it would be replaced by a 30 percent surcharge when someone buys a policy after dropping coverage, the surcharge could be weaker than the current mandate, and younger people might continue to gamble on not having coverage until they get sick.
The result, said Donald H. Taylor Jr., a health policy professor at Duke University, is that people who buy coverage are sicker, causing the cost of premiums to soar. ''This looks like to me adverse selection on steroids,'' he said. ''I don't see how it doesn't crater the individual market.''
Dr. Molina, the Molina Healthcare chief executive, said insurers are likely to increase their premiums significantly because they will worry about enrolling more high-cost patients as healthier people opt to go without coverage.
''Insurance companies are going to jack up the rates,'' predicted Dr. Molina, who said premiums might increase even more than they did last year when some companies raised the rates by 25 percent or more.
Ms. Brawley in Monroe, N.C., said she and her husband could barely afford their current premiums, and her deductible of $3,500 a year is far too high. Still, she added, ''it's better than owing $20,000 or $30,000.''
''This is my second year with the Obama insurance,'' she continued, ''but before then, I didn't have any and didn't go to the doctor.''
She and her husband voted for Mr. Trump -- the first time she had voted in her life -- she said, because ''I thought he would make it better.''
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
URL: http://www.nytimes.com/2017/03/07/health/risk-of-losing-health-insurance-in-republican-plan.html
LOAD-DATE: March 8, 2017
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GRAPHIC: PHOTOS: From top, Martha Brawley of Monroe, N.C., would get $5,188 less in aid for premiums under the Republican plan. Alan Lipsky and his wife, A. J. Rhodes, of Arden, N.C., would see their family's tax credit shrink by more than half. But Joshua Yospyn of Washington would gain a tax credit. (PHOTOGRAPHS BY LOGAN R. CYRUS FOR THE NEW YORK TIMES
MIKE BELLEME FOR THE NEW YORK TIMES
T. J. KIRKPATRICK FOR THE NEW YORK TIMES)
PUBLICATION-TYPE: Newspaper
Copyright 2017 The New York Times Company
417 of 1000 DOCUMENTS
The New York Times
March 10, 2015 Tuesday
Late Edition - Final
Budget Office Again Reduces Its Estimate on Cost of the Affordable Care Act
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 777 words
WASHINGTON -- The Congressional Budget Office on Monday again lowered its estimate of the cost of the Affordable Care Act, citing slow growth of health insurance premiums as a major factor.
Just since January, the budget office said, it has reduced its estimate of the 10-year cost of federal insurance subsidies by 20 percent, and its estimate of new Medicaid costs attributable to the law has come down by 8 percent.
Slower growth in health spending helps consumers and businesses, which shoulder most of the costs, and contributes to lower federal budget deficits.
The budget office now projects deficits totaling $7.2 trillion from 2016 to 2025, a decrease of 6 percent from the more than $7.6 trillion projected in January.
''The largest factor underlying that reduction is a downward revision in projected growth in premiums for private health insurance,'' reflecting the fact that spending by private insurers in 2013 rose less than in preceding years and much less than expected, the budget office said in a new report.
The new estimates could help Democrats stave off Republican efforts to roll back the law. Even though millions of people have gained coverage, opinion polls show that unfavorable views of the law are still more common than favorable ones.
Josh Earnest, the White House press secretary, said the new estimates were ''the latest in a long line of data points that indicate the Affordable Care Act is contributing in a very positive way to holding down the growth of health care costs.''
''Unrestrained growth in health care costs did pose a threat to our government's finances'' and contributed to ''some weakness in our economy,'' Mr. Earnest said, and he asserted that the law was reversing those trends.
The budget office has repeatedly lowered its estimate of the cost of the health care law since the bill was signed by President Obama in March 2010. At that time, the budget office said that the law's insurance-related provisions would cost the federal government $710 billion from 2015 through 2019, the last year of the 10-year projection period used then.
On Monday, Douglas W. Elmendorf, the director of the Congressional Budget Office, said the new projections indicated that ''the cost will be $506 billion for that same period, a reduction of 29 percent.''
Much of the reduction can be attributed to the subsidies. Five years ago the budget office predicted that people receiving financial assistance through health insurance exchanges would receive subsidies averaging $5,200 a person in 2015. On Monday, it said that subsidies this year would average $3,960 for each person receiving assistance.
The budget office now estimates that the federal government will spend a total of $849 billion on insurance subsidies in the coming decade -- $209 billion or 20 percent less than it estimated in January of this year.
With premiums rising more slowly, fewer health plans will have to pay a new excise tax on high-cost insurance, which takes effect in 2018. Projected revenues from the so-called Cadillac tax from 2018 to 2025 have plunged more than 40 percent.
But at the same time, the budget office said, the government will collect more in payroll and income taxes, because workers will get more of their compensation in taxable wages and less in tax-free fringe benefits like employer-sponsored health insurance.
The budget office made small changes in its estimates of insurance coverage for the coming decade. It said that fewer people would lose employment-based coverage, and fewer would gain coverage through public insurance marketplaces and Medicaid. In addition, it said, somewhat fewer people will remain uninsured -- 24 million in 2017-19, compared with its earlier estimate of 26 million.
Mr. Elmendorf estimated that new federal Medicaid costs resulting from the health care law would total $847 billion in the coming decade, down $73 billion or 8 percent from the agency's estimate in January.
The budget office sounded a cautionary note about premiums for health plans sold on the exchanges. In general, it said, these plans have been paying doctors and hospitals less than employer-sponsored plans, and they have held down costs by limiting consumers' choice of providers.
''Many plans will not be able to sustain such low provider payment rates or such narrow networks over the next few years,'' and this will put ''upward pressure'' on premiums in the exchanges, the budget office predicted.
After six years running the budget office, Mr. Elmendorf plans to step down next month, to be replaced by Keith Hall, who was the commissioner of labor statistics from January 2008 to January 2012.
URL: http://www.nytimes.com/2015/03/10/us/politics/budget-office-again-reduces-its-estimate-on-cost-of-the-affordable-care-act.html
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The New York Times Blogs
(Economix)
December 19, 2012 Wednesday
A Tale of Two Welfare States
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 635 words
HIGHLIGHT: Britain's determination to unify its antipoverty programs and the United States' creation of more programs will offer a sharp contrast in policy making, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
In "A Tale of Two Cities," Dickens wrote, "It was the age of wisdom, it was the age of foolishness." The governments of the United States and Britain are embarking on different approaches to helping their poor and unemployed, and one of them may regret its policy decisions.
As recently as 2010, Britain had a complex system of antipoverty programs ranging, including housing benefits, job seekers' allowances and mortgage-interest assistance. With so many benefits available, many people found they could make almost as much from the combined programs as they could from working, even while any one of the benefits might not have been all that significant by itself. As Britain's Department for Work and Pensions described, beneficiaries remained "trapped on benefits for many years as a result."
Beginning next month, Britain will strive to put its welfare system on a different path by unifying many programs under a single "universal credit" system, what the department describes as an "integrated working-age credit that will provide a basic allowance with additional elements for children, disability, housing and caring." The department forecasts that its "universal credit will improve financial work incentives by ensuring that support is reduced at a consistent and managed rate as people return to work and increase their working hours and earnings."
In the United States, the welfare system includes dozens of federal programs, enumerated by Robert Rector of the Heritage Foundation as those "providing cash, food, housing, medical care, social services, training and targeted education aid to poor and low-income Americans." Beginning in 2014, more programs will be added and expanded by the Patient Protection and Affordable Care Act: new health-insurance premium-support programs, new cost-sharing subsidies for out-of-pocket health expenditures, financial hardship relief from the new individual mandate penalties, new subsidies for small businesses employing low-income people and expansion of Medicaid.
The Congressional Budget Office estimates that the Affordable Care Act's means-tested subsidies and cost-sharing will implicitly add more than 20 percentage points to marginal tax rates on incomes below 400 percent (see Page 27 of the C.B.O. report) of the poverty line (a majority of families fit in this category) by phasing out the assistance as family incomes increase, although a number of families will not receive the subsidies because they already get health insurance from their employer.
These marginal tax-rate additions are on top of the marginal tax rates already in place because of personal income taxes, payroll taxes, unemployment insurance, food stamps and other taxes and means-tested government programs. In 2014, some Americans will be able to make almost as much from combined benefits as they would by working, and sometimes more.
In summary, the United States intends to move in the direction of more assistance programs and higher marginal tax rates, while Britain intends to move in the direction of fewer programs and lower marginal tax rates.
Either country, or both, may ultimately fail to fully carry out the new programs by granting waivers and exceptions, refusing to administer them or by rewriting its new laws. But if both do follow through, perhaps future empirical economic research comparing the United States and Britain will reveal which country is living an age of wisdom and which one in an age of foolishness.
The Microeconomics of Poverty Since 2007
Poverty Should Have Risen
The 'Go Fast' and 'Go Big' Fiscal Challenges
Testing for Need
Millions Caught by the Social Safety Net
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The New York Times Blogs
(Opinionator)
March 21, 2012 Wednesday
Never Before
BYLINE: LINDA GREENHOUSE
SECTION: OPINION
LENGTH: 1464 words
HIGHLIGHT: The constitutional challenge to the Affordable Health Care Act is rhetorically powerful but analytically so weak that it dissolves on inspection.
Journalistic convention requires that when there are two identifiable sides to a story, each side gets its say, in neutral fashion, without the writer's thumb on the scale. This rule presents a challenge when one side of a controversy obviously lacks merit. But mainstream journalism has learned to navigate those challenges, choosing evolution over "intelligent design," for example, and treating climate change naysayers as cranks.
Court cases are trickier. It's one thing to engage in prediction that flows from analysis: which side is most likely to win? It's quite another to let readers in on the fact that one side's argument is so manifestly weak that it doesn't deserve to win. Journalistic accounts of court cases, at least in advance of a definitive ruling, understandably tend to take the safe course and treat the arguments on both sides with equal dignity. So it's perhaps not surprising that just about half the public apparently believes that the Affordable Care Act's individual mandate is unconstitutional.
Free of convention, and fresh from reading the main briefs in the case to be argued before the Supreme Court next week, I'm here to tell you: that belief is simply wrong. The constitutional challenge to the law's requirement for people to buy health insurance -- specifically, the argument that the mandate exceeds Congress's power under the Commerce Clause -- is rhetorically powerful but analytically so weak that it dissolves on close inspection. There's just no there there.
Maybe the court will agree with that assessment, and maybe it won't. I think it will, by a wide margin, but that isn't my point; the justices will do what they will do. Going into as dramatic a week at the Supreme Court as I can recall (the argument in Bush v. Gore was over in 90 minutes, compared with the six hours the justices have allocated to the Affordable Care Act), my concern is that the three-day marathon may leave people muddled and confused about something that is really quite simple and clear. So I want to unpack the challengers' Commerce Clause argument for what it is: just words.
Basically just one word, in fact: "unprecedented." Did you know that the individual mandate is unprecedented? You will after you read the brieffiled by the redoubtable Paul D. Clement, the former solicitor general, on behalf of the 26 states that filed suit to challenge the law. The brief uses the word "unprecedented" 10 times, by my count -- I probably missed some -- not counting such other formulations of the same thought as "novel" and "first " O.K., I get it. I'll even accept it as true: granted that passage of the Affordable Care Act ended decades of deadlock over how to reform the developed world's most irrational health care system. It should have happened much earlier.
Unprecedented is a description, not an analysis. What's unprecedented is the singular determination of the Republicans both on Capitol Hill and in the statehouses to deprive President Obama of his major domestic achievement. Republican officeholders in all 26 states joined together in the case now known as United States Department of Health and Human Services v. State of Florida. In 22 of those states, the officeholder was the attorney general. In four states with Democratic attorneys general (Nevada, Wyoming, Iowa and Mississippi), Republican governors filed in their own names. If any of them noted any irony in the fact that not so long ago, the individual mandate was an idea cooked up by conservative policy wonks to counter more fundamental reform sought by the Clinton administration, they offer no sign.
The countless unprecedented things that Congress has done over the centuries were not, for that reason, unconstitutional. Social Security, Medicare, the Employee Retirement Income Security Act (Erisa), and the Emergency Medical Treatment and Labor Act, the 1986 law passed to prevent hospitals from refusing to care for uninsured patients in acute distress, all come to mind. (From the perspective of today's toxic politics, it's a miracle that any of these laws actually got passed, but that's a separate issue.) So there must be some problem with the Affordable Care Act other than "never before."
As I said, the rhetoric is powerful: "The Constitution protects and promotes individual liberty, while the mandate's threat to liberty is obvious." How so? "It is a revolution in the relationship between the central government and the governed." In what respect? Beyond regulating commerce, a power explicitly granted to Congress by Article I of the Constitution, the Affordable Care Act gives Congress "the power to compel individuals to enter into commerce" - a "fundamental" distinction with "breathtaking" implications.
This is the argument that persuaded the two members of the three-judge panel of the Atlanta-based United States Court of Appeals for the 11th Circuit who voted to invalidate the mandate. The government argues that, to the contrary, the "uncompensated consumption of health care" by those who are willfully or helplessly uninsured is itself an enormous economic activity. The uninsured don't exist apart from commerce. To the contrary, their medical care results in some $43 billion of uncovered health care costs annually and, through cost-shifting, adds $1,000 a year to the average cost of a family insurance policy. People who don't want to buy broccoli or a new car can eat brussels sprouts or take the bus, but those without health insurance are in commerce whether they like it or not.
"No one is inactive when deciding how to pay for health care, as self-insurance and private insurance are two forms of action for addressing the same risk." So said Judge Jeffrey S. Sutton of the United States Court of Appeals for the Sixth Circuit in an opinion last summer that rejected a separate challenge to the law. Judge Sutton's high visibility as a star among a younger generation of Republican-appointed federal judges made his opinion particularly notable. The government's main brief quotes him at least six times, by my count.
Just like their opponents, the government lawyers are not above using repetition to hammer home their main points. The government brief repeatedly cites a 2005 Supreme Court decision, Gonzales v. Raich, which upheld Congress's authority to criminalize the private, non-commercial cultivation of marijuana for medicinal purposes. Justice Antonin Scalia wrote a concurring opinion in that case.
Neither Chief Justice John G. Roberts Jr. nor Justice Samuel A. Alito Jr. was on the court then. But two years ago, they both voted with the majority in another case the government cites repeatedly, United States v. Comstock. That decision, a robust interpretation of Congress's authority to pass legislation it deems "necessary and proper," upheld a federal law imposing extended confinement on dangerous sexual predators who have completed their criminal sentences. (A fascinating article in USAToday this week shows that the law, once upheld, is scarcely being used.)
From reading the government's brief, one might conclude that Raich and Comstock were the only two relevant cases in the constitutional firmament. But unlike the "unprecedented" mantra, these recent decisions really do shed light on the contemporary understanding of the scope of congressional authority. If the commerce power extends to backyard marijuana growing (as it did to backyard wheat growing in the famous New Deal case of Wickard v. Filburn), the notion that Congress somehow lacks the power to regulate, restructure or basically do whatever it wants in the health care sector, which accounts for 17 percent of the gross domestic product, is far-fetched on its face.
Indeed, just a few years ago, the constitutional argument against the mandate struck most people who thought about the matter as frivolous. In 2009, the House speaker, Nancy Pelosi, famously replied "Are you serious?" to a question about the bill's constitutionality.
The opponents' argument has been gussied up since then, which brings to mind Barack Obama's remark during the 2008 campaign about putting lipstick on a pig. One of the more depressing news items I've seen lately was the report of a Bloomberg News national poll indicating that 75 percent of people expect that the Supreme Court's health care decision will be influenced by the justices' politics. Only 17 percent predicted that the case would be decided "solely on legal merits." (This from a majority of poll respondents who said the law should be "left alone" or modified only slightly, presumably in the political arena.) Now it's up to the court to prove them wrong.
Rick Santorum Still Isn't Crazy
It's Moderately Super Wednesday!
Rick Santorum Isn't Crazy
Should Obama Have His Own Plan B?
Second Chances
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September 16, 2016 Friday
Late Edition - Final
More Are Insured, but Obamacare's Future Is Very Much in Play
BYLINE: By REED ABELSON and MARGOT SANGER-KATZ
SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1
LENGTH: 1210 words
Included among the many uplifting economic numbers released by the Census Bureau on Tuesday was a remarkable one about health insurance in the United States: Only 9.1 percent of Americans do not have coverage, the lowest level ever recorded by the agency.
That figure is down from 13.3 percent in 2013, before the major provisions of the health care law signed by President Obama went into effect. Another government study, released last week, looked at the first part of 2016 and found that the uninsured rate had fallen even further, to 8.6 percent.
So does that mean the Affordable Care Act is solving the puzzle of getting people covered, a major goal of the law?
It certainly looks that way. About 18 million more people have coverage now than did in 2013.
But the new numbers also highlight where the law is not working well -- and how difficult it will be to drop the uninsured rate much lower.
Many states have continued to resist the Obama administration's entreaties to expand their Medicaid coverage, leaving millions of poor Americans with no affordable health insurance options. And the marketplaces created under the law, in which middle-income people without insurance can buy policies, are struggling in states across the country.
Some insurers are dropping out, and others are sharply raising prices. In New York City, for example, rates for a benchmark plan could go up by an average of 16 percent, according to one analysis.
If the marketplaces do not stabilize, the drop in the uninsured rate could stall or even reverse.
Adding to the uncertainty is the hazy future of the health care law. Donald J. Trump and Republicans in Congress have vowed to repeal it if they get the chance. And even if the Democrats are in control, there is an array of competing proposals on how to adjust the law.
''The way I would frame it is, this isn't just about whether the Affordable Care Act works,'' said Dr. Benjamin D. Sommers, an assistant professor at Harvard's School of Public Health and former researcher for the Health and Human Services Department, who has analyzed the remaining uninsured population. ''It's also about whether the effort to expand coverage has gone far enough.''
The Affordable Care Act was not intended to cover everyone, the way that single-payer systems in many other countries do. Undocumented immigrants, for example, are largely shut out of the health insurance system. And because the system requires people to actively sign up for insurance and often pay a premium, there will always be some Americans too independent -- or isolated -- to seek insurance.
But the law was certainly written to get insurance to far more people.
The Medicaid expansion, for example, is meant to expand coverage to all Americans earning below a set income threshold -- about $16,000 for a single person. Adoption of the program has been substantial. But the Supreme Court dealt a major blow to that plan in 2012. The court determined that states could decide whether to expand, and 19 have still declined to do so.
Those decisions leave more than three million people who are in poverty uninsured and without good options for obtaining health insurance. The law was written to give poor people coverage through Medicaid, not the private marketplace, so it does not provide financial assistance for buying coverage. The census report highlighted an increasing gap in the uninsured rates between states that expanded their programs and states that did not.
There is another large group of low-income Americans -- about nine million, according to recent calculations from the Urban Institute -- who are eligible for Medicaid or the related Children's Health Insurance Program but have not signed up.
The online marketplaces, which play a critical role under the law in reducing the number of people without coverage, also remain volatile. Fewer people than expected have signed up for plans through the marketplaces, and the enticements are not improving. Prices are set to rise substantially next year. And in many places, people who enroll will have fewer insurers to choose from.
Millions of people qualify for subsidies to buy into the plans. But many middle-class people who qualify for small subsidies have still found the plans to be unaffordable or a poor value. And people who make more and do not qualify for much or any government aid -- especially those who are healthy -- have been less likely to enroll. That has kept the mix of people in the pool sicker -- and more expensive to insure -- than expected.
''These gains in coverage don't negate the need to make the insurance marketplaces sustainable,'' Larry Levitt, an executive with the Kaiser Family Foundation, which closely tracks the insurance market, said in an email. ''In fact, coverage needs to grow more, with additional healthy people signing up, to stabilize the individual insurance market.''
Insurers say it is imperative that the people who sign up are not just the sickest people. ''We need to encourage younger and healthier people to enroll,'' said Alissa Fox, a senior executive at the Blue Cross Blue Shield Association, a trade group.
Before the Affordable Care Act, most working-age Americans got insurance from their jobs, and that continues to be true. According to the Census Bureau, employer coverage has held steady since 2013. Many critics of the health law had predicted it would result in a huge drop-off in employer coverage. That has not happened. In fact, the persistent strength of employer coverage has been one of the reasons enrollment in the state marketplaces has not been higher.
On Wednesday, the Kaiser Family Foundation released its annual survey of employer health benefits. It found that the market remained stable, with no appreciable decline in the share of companies offering their employees coverage. While employees are typically paying a greater share of their medical bills, the cost of coverage went up modestly this year.
The future trajectory of the uninsured numbers depends largely on the results of the next election. Though the health care law may have come to bear President Obama's name, as Obamacare, its future will be shaped by the president who replaces him -- and by the next Congress.
Hillary Clinton has proposed an array of policies to expand outreach to the uninsured and increase financial assistance to middle-income Americans buying health insurance, policies designed to bring more people into the health law's programs. She has also proposed introducing public insurance programs for more Americans, including a Medicare buy-in for middle-aged people.
Mr. Trump, in contrast, has said he would repeal the health law and move to a more free-market system for health insurance sales, a proposal that is expected to result in a substantial increase in the number of Americans without health coverage. Republicans in the House have put out their own health proposal, also built on a total repeal of the president's health law.
''The stakes are huge,'' said Linda J. Blumberg, a senior fellow at the Urban Institute, who has suggested a series of policy changes to help expand coverage under the law. ''You couldn't be further apart in terms of the perspectives on what is needed here.''
URL: http://www.nytimes.com/2016/09/16/business/americans-without-health-care-at-record-low-so-whats-the-problem.html
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GRAPHIC: PHOTOS: Craig Dooley, getting an X-ray in Taylorsville, Ky., became eligible for expanded Medicaid coverage under the Affordable Care Act. (PHOTOGRAPH BY LUKE SHARRETT FOR THE NEW YORK TIMES)
A health insurance fair in San Francisco on the first day of open enrollment for Obamacare in November 2015. (PHOTOGRAPH BY JIM WILSON/THE NEW YORK TIMES) (B2)
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(In Practice)
November 2, 2013 Saturday
Health Exchange: A One-Month Checkup
BYLINE: The New York Times
SECTION: US
LENGTH: 339 words
HIGHLIGHT: Success signing up for health insurance under the Affordable Care Act has been elusive for some and a dream come true for others. It often depends on geography.
The Affordable Care Act's goal of providing health insurance for all Americans grew more complicated when governors of more than 30 states
opted not to create their own health care exchanges. That left the federal government responsible for enrolling a much larger portion of the population than it had expected, which is at least part of the reason for the troubled rollout of HealthCare.gov.
"It would be one thing if it was just a federal marketplace with federal plans and federal Medicaid rules, but it's not," said Elisabeth R. Benjamin, a vice president at the Community Service Society of New York that helps enrollees navigate the state exchange website. "That's a pretty big endeavor that you wouldn't really want to pull off in a year or 18 months, which is essentially what they had to do when it became clear that some of these states were opting out."
According to documents released by a House oversight committee, fewer than a dozen people were actually enrolled on Oct. 1, the opening day for HealthCare.gov. To meet the Obama administration's goal of seven million enrollees by March 31, it needs an average of more than 38,000 per day.
"The website right now is kind of give or take, you know?" said Steph Mulvey, a canvasser for the Texas Organizing Project, which aims to help people enroll. "Some people are going on at 3 a.m. and having luck. It's all about when you do it."
For more information on how the health care exchanges are performing, see these graphics from The New York Times:
How HealthCare.gov Was Supposed to Work and How It Didn't
State-by-State Premiums Under the Health Care Law
Tracking the Progress of the Health Exchanges
Why Some People Can't Keep Their Insurance Plans
People Who Buy Own Health Policies Face Big Changes
Awareness Grows of Online Insurance Exchanges, and Their Problems, Survey Finds
Readers Ask How Insurance Subsidies Are Calculated for Students
Readers Ask About Families Who Want Different Plans, and Rise in Costs
Readers Ask About Subsidies and Other Health Care Law Provisions
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The New York Times
December 28, 2015 Monday
Late Edition - Final
Medicaid Brawls in States Reflect Split in the G.O.P.
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; Foreign Desk; Pg. 1
LENGTH: 1394 words
WASHINGTON -- John Thune of South Dakota, the No. 3 Republican in the Senate, voted earlier this month to repeal major provisions of the Affordable Care Act and to end its expansion of Medicaid, arguing that the health law was ''unpopular and unaffordable.''
A week later, his state's Republican governor, Dennis Daugaard, announced that he wanted to make 55,000 additional South Dakota residents eligible for Medicaid under the law.
''I know many South Dakotans are skeptical about expanding Medicaid, and I share some of those sentiments,'' Mr. Daugaard said. ''It bothers me that some people who can work will become more dependent on government.''
''But,'' Mr. Daugaard said, ''we also have to remember those who would benefit, such as the single mother of three who simply cannot work enough hours to exceed the poverty line for her family.''
In state after state, a gulf is opening between Republican governors willing to expand Medicaid coverage through the Affordable Care Act and Republican members of Congress convinced the law is collapsing and determined to help it fail. In recent months, insurers have increased premiums and deductibles for many policies sold online, and a dozen nonprofit insurance co-ops are shutting down, forcing consumers to seek other coverage.
But in Arizona, Arkansas, Indiana, Iowa, Michigan, Nevada, New Jersey, New Mexico and Ohio, Republican governors have expanded Medicaid under the health care law or defended past expansions. In South Dakota, Tennessee and Utah, Republican governors are pressing for wider Medicaid coverage. And Republican governors in a few other states, including Alabama, have indicated that they are looking anew at their options after rejecting the idea in the past.
That has created tension with Washington that some lawmakers can no longer ignore.
''I am very reluctant to take positions that counter the decisions made by the governor,'' said Senator John McCain, Republican of Arizona, where more than 78,000 people have gained Medicaid coverage under legislation signed in 2013 by Jan Brewer, a Republican who was then the governor. Now, Gov. Doug Ducey, also a Republican, is seeking a federal waiver to charge premiums and co-payments and create work incentives within the limits allowed by federal rules.
''The governor and Legislature in my state decided that they wanted'' to expand Medicaid, Mr. McCain said.
Joan C. Alker, a senior researcher at the Health Policy Institute of Georgetown University, said the divide was ''a reflection of the larger fight in the Republican Party between more pragmatic Republicans, including governors, and the ideological wing of the party that wants to stop Obamacare at all costs.''
Tarren Bragdon, the chief executive of the conservative Foundation for Government Accountability, said that to governors of both parties, federal funds looked like ''free money.'' By contrast, he said, Republicans in Congress focus on costs to the federal government and believe that the expansion of Medicaid will not be sustainable or affordable in the long term.
When Democrats wrote the Affordable Care Act, they wanted to make Medicaid available to all Americans under 65 with incomes up to 138 percent of the poverty level -- or $16,240 for an individual. The federal government pays the full cost for newly eligible beneficiaries from 2014 to 2016 and at least 90 percent after that.
In 2012, the Supreme Court ruled that the expansion of Medicaid was an option for states, not a requirement. Thirty states have chosen to expand eligibility, and several others are negotiating with the Obama administration. But state-level brawls over Medicaid expansion have mirrored the wider political war over the law.
Gov. Bill Haslam of Tennessee, a Republican, wanted to use federal Medicaid money to extend coverage to 280,000 low-income people. His proposal failed in the spring in the legislature, under attack by conservative groups like the Koch brothers' Americans for Prosperity, which urged voters to ''stop Obamacare in Tennessee.''
No member of Congress has attacked the Affordable Care Act with more zeal than Senator John Barrasso, Republican of Wyoming. But Gov. Matt Mead of Wyoming, also a Republican, is urging state legislators to expand Medicaid to cover thousands of low-income people.
''When I came into office in 2011, I joined other states in a lawsuit challenging the Affordable Care Act, and I still don't like it,'' Mr. Mead said in an interview. ''But it's the law of land. So now I'm trying to be pragmatic, recognizing that we have about 18,000 people who could obtain coverage. We have small hospitals that are struggling. Our federal tax dollars are not headed back to Wyoming, but are paying for health care in Colorado, California and other states.''
Clinching the case for Mr. Mead is the state's fiscal plight. Revenue is down because of a steep decline in oil and natural gas prices. With the expansion of Medicaid, he said, Wyoming would receive an infusion of federal funds, easing its budget problems.
In Arkansas, a centrist Democratic governor, Mike Beebe, found a novel way to expand Medicaid in 2013, using federal money to buy private coverage for 220,000 low-income people through the insurance exchange set up under the health care law. His successor, Gov. Asa Hutchinson, a Republican, said this month that he wanted to continue the expansion while adding some conservative features, including premiums and work incentives.
''I opposed and continue to oppose the Affordable Care Act,'' Mr. Hutchinson said. But, he added, ''we're a compassionate state, and we're not going to leave 220,000 people without some recourse.''
Ray Hanley, a former director of the Medicaid program in Arkansas, summarized the prevailing sentiment this way: ''We hate Obamacare and would repeal it tomorrow if we could, but we can't. So we must do what is best for Arkansas.''
In Utah, Gov. Gary R. Herbert, a Republican, has been trying for two years to expand Medicaid in some way that would be acceptable to state legislators and federal health officials.
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, has stayed out of the negotiations, but aides said he thought the expansion of Medicaid under the health law was a terrible idea. His Republican colleague from Utah, Senator Mike Lee, said, ''Medicaid's abysmal track record of failing our most vulnerable populations will only get worse as millions of new, able-bodied adults join the program.''
To the authors of the law, Republican intransigence in Washington is baffling. The Senate Democratic leader, Harry Reid of Nevada, said Republicans in Congress ''aren't listening to their constituents or state leaders.'' The Republican governor of his state, Brian Sandoval, expanded Medicaid and remains highly popular.
To this day, many Republicans on Capitol Hill are upset about the way the Affordable Care Act was adopted in 2010 -- rammed through Congress, they say, without any Republican votes and with scant regard for their concerns.
Senator Lamar Alexander, Republican of Tennessee, said he remembered discussing health care with President Obama in early 2010, but, he said, the president and congressional Democrats ''didn't take any of my advice and hardly any of the advice of my Republican colleagues about what the disastrous outcomes of Obamacare would be.'' Medicaid accounts for 30 percent of Tennessee's budget, he said, and expanding eligibility means ''having less to spend on other priorities like higher education, roads and schools.''
In swing states like Ohio, the politics of Medicaid have become challenging.
More than 600,000 Ohio residents have gained coverage under Medicaid since Gov. John R. Kasich expanded eligibility. In his bid for the Republican presidential nomination, Mr. Kasich has come under criticism from conservatives but has defended his action, saying he felt a moral imperative to help the poor.
Senator Rob Portman of Ohio is running his first Senate re-election campaign, in the heat of a presidential election year. He voted with other Republicans to repeal the federal health care law but is cautious in his criticism.
''Medicaid badly needs reform,'' Mr. Portman said. But, he added, ''we must ensure that Ohioans who rely on it for health care don't have a lapse of coverage.''
URL: http://www.nytimes.com/2015/12/28/us/politics/state-level-brawls-over-medicaid-reflect-wider-war-in-gop.html
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The New York Times Blogs
(Economix)
June 21, 2013 Friday
'Premium Shock' and 'Premium Joy' Under the Affordable Care Act
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1708 words
HIGHLIGHT: Changing systems of health insurance that will take effect later this year under the Affordable Care Act will benefit many people, but lead to higher premiums for some, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
Starting on Oct. 1, Americans can purchase individual health insurance in what is known as the nongroup market on the newly established electronic health-insurance exchanges that were called for in the Affordable Care Act of 2010. That coverage will take effect on Jan. 1.
In the meantime, Americans will be bombarded with information on the premiums they will pay for coverage on the exchanges. Much of that information will be pure speculation, and a good part of it will be strategic misinformation (a topic that I will explore more fully in a future post).
So let's review what the new arrangement seeks to accomplish.
Medical Underwriting Under the Traditional Arrangement
Traditionally, the premium that a particular insurer in the nongroup market has quoted an individual applicant can be expressed as
Pi= (1 + L)Xi
Pi denotes the premium quoted to the individual applicant "i." Xi is an actuarial estimate of the insurer's expected outlay for covered health benefits used by that individual "i" in the coming year. L is a "loading factor" added to cover the additional cost of marketing and administration, as well as a target profit margin.
Basing the premium on an individual's health status is known as "medical underwriting." The insurer includes in the application form a lengthy questionnaire on the applicant's current and previous medical conditions and use of health care. Jonathan Cohn has described this process well in The New Republic, drawing particular attention to the long list of medical conditions for which the insurers will reject an applicant.
The number of applicants refused coverage in the nongroup market can be high. In a recent paper by the actuarial benefit consulting firm Milliman, prepared for the Indiana Health Care Exchange Policy Committee, an average of 13 percent of applicants age 35 to 39 and 24 percent of applicants age 55 to 59 were found to have been denied insurance coverage in Indiana's nongroup health insurance market (see Figure 3). Although the rejected individuals might find coverage in a state-run high-risk pool, premiums for that coverage and out-of-pocket expenses tend to be very high.
Until 2012, each insurer was free to set its own load factor L (as in the equation above), constrained only by the market. In the large-group market serving employers with many employees, the load factor tended to range from 15 to 30 percent, corresponding to a ratio of health benefits paid for a premium collected (known as the medical loss ratio) of 75 to 85 percent. In the markets for small groups and individuals, however, the load factor could exceed 80 percent (with a medical loss ratio of 45 percent) This made the premium charged the insured almost double what the insurer paid for health benefits.
Under the Affordable Care Act, effective January 2012, the load factor must be at or below 17.65 percent in the large-group market (a medical loss ratio of not less than 85 percent), and at or below 25 percent in the small group and individual market (a medical loss ratio of not less than 80 percent). By itself, this provision should lower the premiums charged to the insured in the nongroup market.
Community Rating Under the Affordable Care Act
Under the law, an individual health plan selling policies in the small-group and nongroup market - whether it sells policies through the state's exchange or not - will be free to set its own premium for a given policy. But within a given age group, it must apply the same premium to all comers, regardless of their health and their gender. Furthermore, the health plan cannot reject any applicant willing to pay that premium, a provision called "guaranteed issue," or cancel existing policies.
In other words, the Xi based on the individual's health status in the equation above will be replaced by the average expected health spending per insured, with the average calculated over the insurer's entire anticipated risk pool of insured members of a given age. To calculate the average, the insurer must consider as one single risk pool all enrollees in all health plans offered by the insurer, whether or not they are offered on the exchange.
This form of premium setting is known as "community rating." Because it forces healthier individuals to subsidize sicker individuals through the community-rated premiums, it has been much debated.
Community rating invites "cherry-picking" by insurers - i.e., attempts to attract mainly low-risk applicants. To limit the profit potential from cherry-picking, there will be post-enrollment risk adjustments through which funds are transferred from insurers ending up with relatively healthier risk pools to those ending up with relatively higher risk pools.
The community rating under the law is not the pure version found in the social insurance systems of Europe (e.g., Switzerland, the Netherlands and Germany) or Asia, where even age is not considered in setting premiums. Rather, the American version is called adjusted community rating, because it does allow insurers to adjust the community-rated premium for the age of the applicant.
Age-adjusting is done by multiplying the community-rated premium for the youngest members in the expected risk pool by a standard, multiplicative age ratio to be used by all insurers. Thus the quoted premium can increase step by step with age, but only up to a multiplicative factor of 3. At a given age, smokers can be charged up to 1.5 times the regular premium.
The change from what was in place before the Affordable Care Act to post-law arrangements in the nongroup market can be illustrated graphically. In the chart below, we assume initially that all members of a given population are covered by either medically underwritten or community-rated health insurance, with a given package of covered health benefits. The white line represents the premium individuals would have to pay under medical underwriting. The dashed segment of that line is meant to show the actuarial cost and the premium range in which insurers in the real world would reject applicants outright. The green line shows the community-rated premium for this same population. We assume here that age is either not factored into the premium or the population in question is all of the same age, which is why the green line is horizontal.
Premium Shock
As the chart illustrates, a switch from medically underwritten premiums to community-rated ones raises the premiums for the relatively healthier members of the insurer's risk pool. Many of them will suffer what has come to be called premium shock.
Younger and healthier members of the pool should realize that, in effect, they are buying a call option that allows them to buy coverage at a premium far below the high actuarial cost of covering them when they are sicker. The price charged the healthy for this call option is the difference between the premium they must pay and the current lower actuarial cost of covering them.
Furthermore, for Americans in households with incomes below 400 percent of the federal poverty line, the green and red lines exaggerate the impact of the law on their spending. These Americans will be granted often quite generous, income-dependent federal subsidies toward the premiums they face on the exchanges and their out-of-pocket costs for health care. This makes it well-nigh impossible to make general statements, based on averages, about the net after-subsidy impact of the law.
Thus, to compare how an individual currently insured in the nongroup market will fare as of Jan. 1, one should compare the premium the individual pays now - the medically underwritten Pi= (1 + L)Xi as in the equation above - with the net after-subsidy premium:
Pc = (1 + L)Xc - TCi
where Pc now is a common, community-rated premium quoted to all applicants in a given age group, Xc is the expected per-member outlay on health care for the insured, averaged over the insurer's entire risk pool, and TCi is the income-based federal subsidy to which individual "i" may be entitled.
It is now easy to see how opponents of the health care law seeking to denounce it can engage in judicious half-truth. To that end, one compares the premium Pi currently paid by a perfectly healthy individual for a relatively skimpy insurance policy with the community-rated premium Pc, which covers a richer benefit package, and one would not, of course, mention the federal subsidies toward the quoted premium Pc and out-of-pocket costs, which can substantially reduce the overall out-of-pocket outlays for health care of lower-income individuals.
That said, however, some higher-income individuals and small businesses are likely to see their premiums go up as a result of the new regime. Not everyone gains from the change.
Premium Joy
Less frequently noted in commentaries about the law - certainly among its critics - is that the law is likely to bring what I call "premium joy" to individuals and families with health problems. Many such people simply could not afford the high, medically underwritten premiums they were quoted in the traditional nongroup market. This joy will be shared by high-risk applicants who were refused coverage by the insurer, along with people now in high-risk pools.
One major design flaw in the law should be noted.
The law mandates all individuals to have insurance coverage for a stipulated minimum benefit package, a necessary companion of community rating. Because the penalties for disobeying that mandate are so low, many young, healthy people may prefer to pay the penalty and remain uninsured until they fall ill, when they can get community-rated coverage.
That possibility - called "adverse risk selection" - could raise the entire community-rated premium curve from, say, the green curve to the red curve, adding to the premium shock of healthy people. Although the federal subsidies will mitigate this effect for many insured, better approaches are available to deal with this problem.
The New Subsidy for Layoffs
Affordable Care Act Could Be Good for Entrepreneurship
Massachusetts Employees Will Keep Their Health Plans
Patterns of Changes in Health Insurance
Health Coverage Worthy of a Senator
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The New York Times on the Web
Obama's Remarks on Health Care and Surveillance
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The following is a transcript of President Obama's remarks about the health care overhaul and response to a question about electronic surveillance in San Jose, Calif., as provided by the White House:
MR. OBAMA: Good morning, everybody. It is wonderful to see all of you, and I want to thank everybody who is here. I think there's only one problem, and that is that my remarks are not sitting here. People! (Laughter.) By Friday afternoon, things get a little challenged.
QUESTION: Will you answer a question in the --
MR. OBAMA: I'm going to have a -- I'm going to answer a question at the end of the remarks, but I want to make sure that we get the remarks out. People! Oh, goodness. (Laughter.) Oh, somebody is tripping. Folks are sweating back there right now. (Laughter.)
Well, good morning everybody. This afternoon, I'm going to be in Southern California to meet with President Xi of China. But before I leave Northern California, I wanted to take a minute to address something that's happening with the Affordable Care Act in this state, and I wanted to meet with a group of people who are doing some very important work on behalf of California's middle-class families.
These leaders from California's government, the California Endowment, and major Spanish language media outlets have joined together to help implement the Affordable Care Act here in California and to educate folks about how to sign up and shop for quality, affordable plans. And their efforts have already shown some excellent results in the biggest insurance market in the country.
There are two main things that Americans need to know when it comes to the Affordable Care Act and what it means for you.
First of all, if you're one of the nearly 85 percent of Americans who already have insurance, either through Medicare or Medicaid or your employer, you don't have to do a thing. You've just got a wide array of new benefits, better protections and stronger cost controls that you didn't have before, and that will, over time, improve the quality of the insurance that you've got; benefits like free preventive care -- checkups, flu shots, mammograms and contraception.
You are now going to be able to get those things through your insurance where they previously were not -- didn't have to be provided. Protections like allowing people up to the age of 26 to stay on their parent's health care plans, which has already helped 6 million Americans, including [1 million] young Latino Americans.
Cost controls like requiring insurance companies to spend at least 80 percent of the money that you pay in premiums in your actual health care costs, as opposed to administrative costs or CEO pay -- not overhead, but that money has to be spent on you. And if they don't meet that target, they actually have to reimburse you. So in California, we're already getting reports that insurers are giving rebates to consumers and small business owners to the tune of $45 million this year. So already we're seeing millions of dollars of rebates sent back to consumers by insurance companies as a consequence of this law.
All of that is happening because of the Affordable Care Act. All of this is in place right now, already, for 85 percent of Americans who have health insurance. By the way, all of this is what the Republican Party has now voted 37 times to repeal, at least in the House of Representatives. And my suggestion to them has been, let's stop refighting the old battles and start working with people like the leaders who are on stage here today to make this law work the way it's supposed to.
We're focused on moving forward and making sure that this law works for middle-class families. And that brings me to the second thing that people need to know about the Affordable Care Act.
If you're one of nearly 6 million Californians or tens of millions of Americans who don't currently have health insurance, you'll soon be able to buy quality, affordable care just like everybody else.
And here's how. States like California are setting up new, online marketplaces where, beginning on October 1st of this year, you can comparison shop an array of private health insurance plans side-by-side, just like you were going online to compare cars or airline tickets. And that means insurance companies will actually have to compete with each other for your business. And that means new choices.
See, right now, most states don't have a lot of competition. In nearly every state, more than half of all consumers are covered by only two insurers. So there's no incentive to provide you a lot of choices or to keep costs down. The Affordable Care Act changes that.
Beginning next year, once these marketplaces are open, most states will offer new private insurance choices that don't exist today. And based on early reports, about 9 in 10 Americans expected to enroll in these marketplaces live in states where they'll be able to choose between five or more different insurers. So for example, here in California, 33 insurers applied to join the marketplace. Covered California then selected 13 based on access, quality, and affordability, four of which are brand new to your individual market.
So what's happening is through the Affordable Care Act, we're creating these marketplaces with more competition, more choice, and so the question is, what happens to cost?
Now, a lot of the opponents of the Affordable Care Act, they had all kinds of sky-is-falling, doom-and-gloom predictions that not only would the law fail, but what we'd also is costs would skyrocket for everybody. Well, it turns out we're actually seeing that in the states that have committed themselves to implementing this law correctly, we're seeing some good news. Competition and choice are pushing down costs in the individual market just like the law was designed to do.
The 13 insurance companies that were chosen by Covered California have unveiled premiums that were lower than anybody expected. And those who can't afford to buy private insurance will get help reducing their out-of-pocket premiums even further with the largest health care tax cut for working families and small businesses in our history. So about 2.6 million Californians -- nearly half of whom are Latinos -- will qualify for tax credits that will, in some cases, lower their premiums a significant amount.
Now, none of this is a surprise. This is the way that the law was designed to work. But since everybody has been saying how it's not going to happen, I think it's important for us to recognize and acknowledge this is working the way it's supposed to. We've seen similar good news, by the way, not just here in California but in Oregon and Washington. In states that are working hard to implement this law properly, we're seeing it work for people -- for middle-class families, for consumers.
Now, that's not to say that everything is going to go perfectly right away. When you're implementing a program this large, there will be some glitches. There are going to be some hiccups. But no matter what, every single consumer will be covered by the new benefits and protections under this law permanently.
So the bottom line is you can listen to a bunch of political talk out there -- negative ads and fear mongering geared towards the next election -- or alternatively you can actually look at what's happening in states like California right now. And the fact of the matter is through these exchanges, not only are the 85 percent of people who already have health insurance getting better protections, and receiving rebates, and being able to keep their kids on their health insurance until they're 26, and getting free preventive care, but if you don't have health insurance and you're trying to get it through the individual market and it's too expensive or it's too restricted, you now have these marketplaces where they're going to offer you a better deal because of choice and competition.
And if even at those lower rates and better insurance that you're getting through these marketplaces you still can't afford it, you're going to be getting tax cuts and tax credits through the Affordable Care Act that will help you afford it. And that's how we're going to make sure that millions of people who don't currently have health insurance or are getting a really bad deal on their health insurance are finally going to get it.
But -- and here's my final point -- to take advantage of these marketplaces, folks are going to need to sign up. So you can find out how to sign up at HealthCare.gov, or here in California you can sign up at CoveredCA.com. Because quality care is not something that should be a privilege, it should be a right. In the greatest country on Earth, we've got to make sure that every single person that needs health care can get it. And we've got to make sure that we do it in the most efficient way possible.
One last point I'm going to make on this, because there are a lot of people who currently get health insurance through their employers -- the 85 percent who are already out there -- and they may be saying, well, if this law is so great, why is it that my premium still went up? Well, part of what's happening across the country is in some cases, for example, employers may be shifting more costs through higher premiums or higher deductibles or higher copays, and so there may still be folks who are out there feeling increased costs not because of the Affordable Care Act but because those costs are being passed on to workers or insurance companies, in some cases. Even with these laws in place, they're still jacking up prices unnecessarily.
So this doesn't solve the whole problem, but it moves us in the right direction. It's also the reason why we have to keep on implementing changes in how our health care system works to continually drive better efficiency, higher quality, lower cost. We're starting to do that. Health care cost inflation has gone up at the lowest rate over the last three years that we've seen in many, many years. So we're making progress in actually reducing overall health care costs while improving quality, but we're going to have to continue to push on that front as well. That's also part of what we're doing in the Affordable Care Act.
But the main message I want for Californians and people all across the country -- starting on October 1st, if you're in the individual market, you can get a better deal. If you're a small business that's providing health insurance to your employees, you can get a better deal through these exchanges. You've got to sign up: HealthCare.gov, or here in California at CoveredCA.com.
All right? So thank you very much.
QUESTION: Mr. President?
MR. OBAMA: I'm going to take one question. And then, remember, people are going to have opportunities to also -- answer questions when I'm with the Chinese President today. So I don't want the whole day to just be a bleeding press conference. But I'm going to take Jackie Calmes' question.
QUESTION: Mr. President, could you please react to the reports of secret government surveillance of phones and Internet? And can you also assure Americans that the government -- your government doesn't have some massive secret database of all their personal online information and activities?
MR. OBAMA: Yes. When I came into this office, I made two commitments that are more important than any commitment I made: Number one, to keep the American people safe; and number two, to uphold the Constitution. And that includes what I consider to be a constitutional right to privacy and an observance of civil liberties.
Now, the programs that have been discussed over the last couple days in the press are secret in the sense that they're classified. But they're not secret in the sense that when it comes to telephone calls, every member of Congress has been briefed on this program. With respect to all these programs, the relevant intelligence committees are fully briefed on these programs. These are programs that have been authorized by broad bipartisan majorities repeatedly since 2006.
And so, I think at the outset, it's important to understand that your duly elected representatives have been consistently informed on exactly what we're doing. Now, let me take the two issues separately.
When it comes to telephone calls, nobody is listening to your telephone calls. That's not what this program is about. As was indicated, what the intelligence community is doing is looking at phone numbers and durations of calls. They are not looking at people's names, and they're not looking at content. But by sifting through this so-called metadata, they may identify potential leads with respect to folks who might engage in terrorism. If these folks -- if the intelligence community then actually wants to listen to a phone call, they've got to go back to a federal judge, just like they would in a criminal investigation.
So I want to be very clear -- some of the hype that we've been hearing over the last day or so -- nobody is listening to the content of people's phone calls. This program, by the way, is fully overseen not just by Congress, but by the FISA Court -- a court specially put together to evaluate classified programs to make sure that the executive branch, or government generally, is not abusing them, and that it's being carried out consistent with the Constitution and rule of law.
And so, not only does that court authorize the initial gathering of data, but -- I want to repeat -- if anybody in government wanted to go further than just that top-line data and want to, for example, listen to Jackie Calmes' phone call, they would have to go back to a federal judge and indicate why, in fact, they were doing further probing.
Now, with respect to the Internet and emails -- this does not apply to U.S. citizens and it does not apply to people living in the United States. And again, in this instance, not only is Congress fully apprised of it, but what is also true is that the FISA Court has to authorize it.
So in summary, what you've got is two programs that were originally authorized by Congress, have been repeatedly authorized by Congress, bipartisan majorities have approved on them, Congress is continually briefed on how these are conducted. There are a whole range of safeguards involved, and federal judges are overseeing the entire program throughout. We're also setting up -- we've also set up an audit process, when I came into office, to make sure that we're, after the fact, making absolutely certain that all the safeguards are being properly observed.
Now, having said all that, you'll remember when I made that speech a couple of weeks ago about the need for us to shift out of a perpetual war mindset, I specifically said that one of the things that we're going to have to discuss and debate is how are we striking this balance between the need to keep the American people safe and our concerns about privacy? Because there are some tradeoffs involved.
I welcome this debate. And I think it's healthy for our democracy. I think it's a sign of maturity, because probably five years ago, six years ago, we might not have been having this debate. And I think it's interesting that there are some folks on the left but also some folks on the right who are now worried about it who weren't very worried about it when there was a Republican President. I think that's good that we're having this discussion.
But I think it's important for everybody to understand -- and I think the American people understand -- that there are some tradeoffs involved. I came in with a healthy skepticism about these programs. My team evaluated them. We scrubbed them thoroughly. We actually expanded some of the oversight, increased some of safeguards. But my assessment and my team's assessment was that they help us prevent terrorist attacks. And the modest encroachments on the privacy that are involved in getting phone numbers or duration without a name attached and not looking at content, that on net, it was worth us doing. Some other folks may have a different assessment on that.
But I think it's important to recognize that you can't have 100 percent security and also then have 100 percent privacy and zero inconvenience. We're going to have to make some choices as a society. And what I can say is that in evaluating these programs, they make a difference in our capacity to anticipate and prevent possible terrorist activity. And the fact that they're under very strict supervision by all three branches of government and that they do not involve listening to people's phone calls, do not involve reading the emails of U.S. citizens or U.S. residents absent further action by a federal court that is entirely consistent with what we would do, for example, in a criminal investigation -- I think on balance, we have established a process and a procedure that the American people should feel comfortable about.
But, again, these programs are subject to congressional oversight and congressional reauthorization and congressional debate. And if there are members of Congress who feel differently, then they should speak up. And we're happy to have that debate.
Okay? All right. And we'll have a chance to talk further over the course of the next couple of days.
QUESTION: Do you welcome the leaks, sir? Do you welcome the leaks? Do you welcome the debate?
MR. OBAMA: I don't welcome leaks, because there's a reason why these programs are classified. I think that there is a suggestion that somehow any classified program is a ''secret'' program, which means it's somehow suspicious.
The fact of the matter is in our modern history, there are a whole range of programs that have been classified because -- when it comes to, for example, fighting terror, our goal is to stop folks from doing us harm. And if every step that we're taking to try to prevent a terrorist act is on the front page of the newspapers or on television, then presumably the people who are trying to do us harm are going to be able to get around our preventive measures. That's why these things are classified.
But that's also why we set up congressional oversight. These are the folks you all vote for as your representatives in Congress, and they're being fully briefed on these programs. And if, in fact, there was -- there were abuses taking place, presumably those members of Congress could raise those issues very aggressively. They're empowered to do so.
We also have federal judges that we put in place who are not subject to political pressure. They've got lifetime tenure as federal judges, and they're empowered to look over our shoulder at the executive branch to make sure that these programs aren't being abused.
So we have a system in which some information is classified, and we have a system of checks and balances to make sure that it's not abused. And if, in fact, this information ends up just being dumped out willy-nilly without regard to risks to the program, risks to the people involved -- in some cases, on other leaks, risks to personnel in a very dangerous situation -- then it's very hard for us to be as effective in protecting the American people.
That's not to suggest that you just say, trust me; we're doing the right thing; we know who the bad guys are. And the reason that's not how it works is because we've got congressional oversight and judicial oversight. And if people can't trust not only the executive branch but also don't trust Congress and don't trust federal judges to make sure that we're abiding by the Constitution, due process and rule of law, then we're going to have some problems here.
But my observation is, is that the people who are involved in America's national security, they take this work very seriously. They cherish our Constitution. The last thing they'd be doing is taking programs like this to listen to somebody's phone calls.
And by the way, with respect to my concerns about privacy issues, I will leave this office at some point, sometime in the last -- next three and a half years, and after that, I will be a private citizen. And I suspect that, on a list of people who might be targeted so that somebody could read their emails or listen to their phone calls, I'd probably be pretty high on that list. It's not as if I don't have a personal interest in making sure my privacy is protected.
But I know that the people who are involved in these programs, they operate like professionals. And these things are very narrowly circumscribed. They're very focused. And in the abstract, you can complain about Big Brother and how this is a potential program run amuck, but when you actually look at the details, then I think we've struck the right balance.
Thank you very much, guys.
URL: http://www.nytimes.com/2013/06/08/us/obamas-remarks-on-health-care-and-surveillance.html
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Late Edition - Final
Trump Orders Swift Remake of Health Act
BYLINE: By MAGGIE HABERMAN and ROBERT PEAR; Margot Sanger-Katz and Emmarie Huetteman contributed reporting.
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President-elect Donald J. Trump demanded on Tuesday that Congress immediately repeal the Affordable Care Act and pass another health law quickly. His remarks put Republicans in the nearly impossible position of having only weeks to replace a health law that took nearly two years to pass.
''We have to get to business,'' Mr. Trump told The New York Times in a telephone interview. ''Obamacare has been a catastrophic event.''
Mr. Trump appeared to be unclear both about the timing of already scheduled votes in Congress and about the difficulty of his demand -- a repeal vote ''probably some time next week'' and a replacement ''very quickly or simultaneously, very shortly thereafter.''
But he was clear on one point: Plans by congressional Republicans to repeal the health law now, then take years to create and implement a replacement law are unacceptable to the incoming president.
Republican leaders have made the repeal of President Obama's signature domestic achievement a top priority. They hope that the Senate will vote on Thursday and the House will vote on Friday to approve parliamentary language created to protect repeal legislation from a filibuster in the Senate.
The House speaker, Paul D. Ryan of Wisconsin, who consults often with Mr. Trump, set out a similar timetable on Tuesday, saying that a bill to repeal the health care law would include some legislation to replace aspects of it, though Republicans have yet to agree on the details of their alternative.
''It is our goal to bring it all together concurrently,'' Mr. Ryan said.
But those ambitions will be difficult to achieve and will almost certainly require Democratic cooperation. Until now, Republicans could vote to repeal Mr. Obama's health law with no fear that they would have to live with the political consequences of scuttling a law that provides health care for 20 million Americans and protects millions more from discrimination for pre-existing medical conditions, ends lifetime caps on insurance coverage and allows children to remain on their parents' insurance policies until age 26.
With complete control of Washington, what comes next in health policy will belong to the Republican Party. For several days, congressional Republicans of diverse political views -- moderates and conservatives alike -- have been saying they are nervous about repealing the law without any clear path forward. Five Senate Republicans have pressed to delay the deadline for committees to produce repeal legislation until March, and several House Republicans are also demanding that the pace slow down.
''In an ideal situation, we would repeal and replace Obamacare simultaneously, but we need to make sure that we have at least a detailed framework that tells the American people what direction we're headed,'' said one of those five Republicans, Senator Susan Collins of Maine.
As it stands, the budget resolution that will fast-track that vote gives Senate and House committees until Jan. 27 to write legislation that would repeal major provisions of the health care law. But the schedule for action on that legislation, its effective date and the timetable for phasing in a new system of health insurance coverage are all unresolved questions.
Even the Jan. 27 deadline is not enforceable or particularly meaningful, Senate aides said, indicating that Congress could follow any timetable its leaders might prescribe.
That uncertainty apparently persuaded Mr. Trump to leap into the fray. Not only did he try to steel Republican spines, but he threatened Democrats who might stand in his way, saying he would campaign against them, especially in states that he won in November.
''It may not get approved the first time, and it may not get approved the second time, but the Democrats who will try not to approve it'' will be at risk, he said, warning that ''they have 10 people coming up'' for re-election in 2018. That alluded to Democratic senators in states he won.
''I won some of those states by numbers that nobody has seen. I will be out there campaigning,'' he said.
He described the health law as a catastrophe. ''I feel that repeal and replace have to be together, for, very simply, I think that the Democrats should want to fix Obamacare,'' he said. ''They cannot live with it, and they have to go together.''
After meeting on Tuesday with House Republicans, Mr. Ryan took a similar tone, calling the campaign to repeal the health law ''a rescue mission to save families who are getting caught up in the death spiral that has become Obamacare.''
Aides to Mr. Ryan said the effort to dismantle the Affordable Care Act would include not only the main bill that would be protected from a filibuster in the Senate, but also legislation that would not enjoy such protections. That legislation would take Democratic cooperation to be passed because Senate Republicans are eight votes short of a filibuster-proof majority.
Congressional Democrats say that the Affordable Care Act, far from being in a ''death spiral,'' is one of the best health laws since the creation of Medicare and Medicaid in 1965. And the Obama administration reported on Tuesday that more than 11.5 million people nationwide had signed up for health insurance or been automatically re-enrolled under the Affordable Care Act as of Dec. 24, 2016, an increase of nearly 300,000 from this time last year.
Of that total, officials said, more than 8.7 million people came in through HealthCare.gov, the online federal marketplace, and 2.8 million were enrolled in states using their own marketplace platforms.
''Today's data show that this market is not merely stable, it is actually on track for growth,'' Aviva Aron-Dine, a senior counselor to Sylvia Mathews Burwell, the secretary of health and human services, said in a conference call with reporters. ''Today we can officially proclaim these death spiral claims dead.''
The fourth annual open enrollment period started on Nov. 1 and ends on Jan. 31, 11 days after Mr. Trump's inauguration.
The enrollment numbers have some Republicans nervous. ''The fear is that the strategy is repeal and delay, and then hope for the best, when we should be planning for the worst,'' said Representative Charlie Dent of Pennsylvania, a chairman of the moderate Republican caucus known as the Tuesday Group.
Republican leaders tried on Tuesday to ease such concerns. But they may be making promises that will be difficult to keep.
''Let me be clear,'' Representative Cathy McMorris Rodgers of Washington, the chairwoman of the House Republican Conference, told reporters. ''No one who has coverage because of Obamacare today will lose that coverage. We're providing relief. We aren't going to pull the rug out from anyone.''
The Obama administration also provided new information to Congress on Tuesday about one of the most unpopular provisions of the health care law, which imposes tax penalties on people who go without insurance and do not qualify for an exemption from the requirement to have coverage.
The commissioner of the Internal Revenue Service, John A. Koskinen, reported that 6.5 million taxpayers were subject to penalties last year. The penalties totaled $3 billion, he said. The average payment was about $470.
Under another section of the health law, low- and moderate-income people can obtain subsidies, in the form of tax credits, to help pay for insurance bought through a public marketplace. In 2016, Mr. Koskinen said, 5.3 million taxpayers claimed $19.2 billion in premium tax credits, for an average of about $3,620.
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URL: http://www.nytimes.com/2017/01/10/us/repeal-affordable-care-act-donald-trump.html
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November 10, 2016 Thursday
Late Edition - Final
Republicans in Congress Plan Swift Action on Ambitious Agenda With Trump
BYLINE: By JENNIFER STEINHAUER; Monica Davey contributed reporting from Chicago, and Carl Hulse from Washington.
SECTION: Section P; Column 0; Politics; Pg. 14
LENGTH: 1243 words
WASHINGTON -- Congressional Republicans, stunned by their own good, if complicated, fortune, said on Wednesday that they would move quickly next year on an agenda that merges with President-elect Donald J. Trump's, repealing the Affordable Care Act, cutting taxes, confirming conservative judges, shrinking government programs and rolling back regulations.
Like much of the nation, groggy Republicans were still trying to process results that were the opposite of what most had anticipated. Many Republicans in the House and Senate largely avoided Mr. Trump during his campaign, while a handful outright denounced him, largely to their peril. In the Senate, two incumbents and one Republican challenger who rejected Mr. Trump lost. Republicans appeared likely to secure a 52-to-48 majority in the Senate.
Mr. Trump's victory provides what Republicans have been seeking for a decade: unified control of the government and a chance to pursue a conservative agenda, transforming them from the ''party of no'' into a party that can enact significant legislation.
And on Wednesday, congressional leaders said major parts of their agenda could get to the new president's desk quickly.
''The goal would be to try and get on the same page,'' Senator Mitch McConnell of Kentucky, the majority leader -- who was about as close as the taciturn leader comes to giddy -- said as he celebrated the Republican victories at the Capitol.
''We're going to be an enthusiastic supporter almost all the time,'' he said of Mr. Trump. ''When we have differences of opinion, I prefer that we work them out in private.''
President Obama's signature domestic achievement, the Affordable Care Act, was clearly in Republicans' sights.
''This health care law is collapsing of its own weight,'' Speaker Paul D. Ryan said from Wisconsin, adding that Congress had already shown it could get a repeal bill to the president's desk without any Democratic help. Republicans are widely believed to favor a maneuver used in budgeting that would allow them to undo the law without facing a Democratic filibuster.
Mr. McConnell demurred Wednesday on the process, but said repealing the law, which has provided health care coverage for 20 million people, is ''pretty high on our agenda,'' adding, ''I would be shocked if we didn't move forward and keep our commitment to the American people.''
Other issues that converge with the new president's include the confirmation of a conservative Supreme Court justice to fill a vacancy from the death of Antonin Scalia early this year, the reduction of climate and other regulations on businesses and Wall Street, and the diminution of the role of the federal government in an array of policy areas like education.
But other priorities are far from shared. Mr. Trump spent his campaign deriding many of the cornerstone principles of his party: free trade, changes in Social Security and the United States' posture toward Russia.
''It's just our constitutional duty to keep the executive branch in check,'' Senator-elect Todd Young, Republican of Indiana, said Wednesday.
Mr. Trump also agrees with Republicans on sharp tax cuts for businesses and most American households, especially the wealthiest. The nonpartisan Tax Policy Center estimated that Mr. Trump's plan would cut federal revenue by $6.2 trillion over the next decade. Mr. McConnell said Wednesday that Republicans craved comprehensive tax reform, an area where Democrats and Republicans remained deeply divided.
Mr. McConnell, who took a political risk that paid off when he refused to act for eight months on Mr. Obama's Supreme Court nomination of Judge Merrick B. Garland, said he looked forward to advising Mr. Trump on a nominee, but would not say whether Republicans would invoke a rules change to prevent Democrats from filibustering Mr. Trump's choice.
However, he hinted that they would avoid doing so, saying that majorities should not ''overreach'' after a big election win. ''I think it's always a mistake to misread your mandate,'' Mr. McConnell said. ''I don't think we should act as if we're going to be in power forever.''
Mr. Trump has been more impulsive than ideological in his policy goals. He has at times provided scant details, and at others reversed or greatly scaled back his stated goals, such as barring Muslims from entering the country.
Mr. Trump could work with Democrats in some areas, such as repealing carried interest deductions that benefit some investors, an action most Republicans oppose.
And he would like to invest in the nation's highways, bridges and other infrastructure, a goal Democrats and Republicans share, though the parties do not agree on how to pay for a large-scale public works package.
Representative Nancy Pelosi of California, the Democratic leader, called Mr. Trump on Wednesday to push for a ''robust infrastructure jobs bill.''
On this front, Mr. Trump could conceivably work with Senator Chuck Schumer of New York, the presumed incoming Democratic leader, who said he had already talked to Mr. Trump.
''It is time for the country to come together and heal the bitter wounds from the campaign,'' Mr. Schumer said in a statement.
The biggest question going into the next Congress will be how Mr. Trump deals with Mr. Ryan, a frequent critic during the campaign. Mr. Trump often returned fire, notably when Mr. Ryan said he could no longer defend Mr. Trump's more incendiary remarks and disinvited him from a campaign swing in Wisconsin.
But in Mr. Ryan, Mr. Trump has a built-in policy factory with a largely supportive caucus; if he signals his support for Mr. Ryan, if not all of his ideas, the two could probably forge a path forward.
''Nothing unites a political party more than a big win,'' said John Feehery, a former top Republican congressional aide. ''I expect G.O.P. leaders to work closely with the new Trump administration. They don't have much of a choice at this juncture.''
Vice President-elect Mike Pence is also expected to be a bridge between the White House and Capitol Hill, and Mr. McConnell said he expected him to take on a role similar to that of former Vice President Dick Cheney, possibly attending weekly lunches with the Republican conference.
Beyond Washington, Tuesday was a good night for Republicans generally.
The party held onto the House with few losses, and made moderate gains at the state level, adding to the broad control it has been building in the states since 2010.
While Democrats had hoped the election would be a chance to start retaking ground in the states and Mr. Obama had directly worked on behalf of more than 150 local Democrats, Republicans gained at least three new governor's offices on Tuesday. It was unclear whether they would hold on to the governor's office in North Carolina, where final results were not expected until later this month.
In state legislatures, where Democrats had seen more opportunities, Republicans, who effectively controlled 68 of 99 chambers before Election Day, gained control of at least the Kentucky House and the Iowa Senate.
With votes in some states still being counted on Wednesday, Democrats did take some chambers, but the scope of wins was nowhere near as large as they had hoped; they took control of the New Mexico House and both chambers in Nevada.
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URL: http://www.nytimes.com/2016/11/10/us/politics/republicans-congress-paul-ryan.html
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Health Care Ruling: The Wordle
BYLINE: CATHERINE RAMPELL
SECTION: BUSINESS; economy
LENGTH: 78 words
HIGHLIGHT: For readers who want to get a flavor of the language and themes in today's Supreme Court ruling without reading all 193 pages, here's a word cloud showing the most commonly used terms
For readers who want to get a flavor of the language and themes in today's Supreme Court ruling without reading all 193 pages, here's a word cloud showing the most commonly used terms:
Odd that broccoli doesn't show up here. It appears in the text 12 times.
Awaiting the Supreme Court's Health Care Ruling
The Supreme Court and the National Conversation on Health Care Reform
Alternatives to the Mandate
How Wider Coverage Affects Health Spending
Further Reading on Mr. Mandate
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February 11, 2014 Tuesday
Late Edition - Final
Further Delays for Employers in Health Law
BYLINE: By ROBERT PEAR; Jonathan Weisman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1075 words
WASHINGTON -- The Obama administration announced on Monday that it would postpone enforcement of a federal requirement for medium-size employers to provide health insurance to employees and allow larger employers more flexibility in how they provide coverage.
The delay is the latest in a series of policy changes, extensions and clarifications by the administration, and it drew a new round of criticism from congressional Republicans, whose scorching attacks on the law have become a central theme in many of this year's midterm election campaigns.
The ''employer mandate,'' which was originally supposed to take effect last month, had already been delayed to Jan. 1, 2015, and now the administration says that employers with 50 to 99 employees will not have to comply until 2016 -- allowing Democrats to placate business concerns and pushing the issue well beyond this year's midterm elections.
In addition, the administration said the requirement would be put into effect gradually for employers with 100 or more employees. Employers in this category will need to offer coverage to 70 percent of full-time employees in 2015 and 95 percent in 2016 and later years, or they will be subject to tax penalties.
''Today's final regulations phase in the standards to ensure that larger employers either offer quality affordable coverage or make an employer responsibility payment starting in 2015,'' said Mark J. Mazur, the assistant Treasury secretary for tax policy. The purpose of the penalty, he said, is to help offset the cost to taxpayers of providing coverage or subsidies to people who cannot get affordable health insurance at work.
Under the law, employers with fewer than 50 full-time employees are generally exempt from the requirement to offer coverage.
The administration described the new policy as a form of ''transition relief'' to help employers adjust to requirements of the 2010 health care law.
But congressional Republicans jumped on the delay as only the latest maneuver by the Obama administration to sidestep the health care law's legal requirements for political gain. Republicans denounced the unilateral move as a violation of the law and called on the White House to throw out all of the Affordable Care Act's coverage mandates.
''The White House seems to have a new exemption from its failed law for a different group each month,'' said Senator Mitch McConnell of Kentucky, the Republican leader, who is in a competitive race himself. ''It's time to extend that exemption to families and individuals -- not just businesses.''
But the House Democratic leader, Representative Nancy Pelosi of California, praised the White House, saying the final rules showed ''the administration's commitment to smoothly implement the Affordable Care Act.''
Coming on the heels of a government analysis of the law's impact on the work force, the delay is likely to breathe new life into the Republican effort to make the health care law the central issue in the coming midterm elections. Several lines of attack, which started with the disastrous rollout of the Healthcare.gov website in October and shifted to a wave of insurance cancellation notices in November, have largely run their course as the website's problems came under control and canceled policies were replaced.
''Once again, the president is rewriting law on a whim,'' said Speaker John A. Boehner. ''If the administration doesn't believe employers can manage the burden of the law, how can struggling families be expected to?''
That theme was echoed by many Republicans, who say it is unfair for the White House to grant a dispensation to employers but not to individuals and families. Democrats see the individual mandate as more important to the operation of the law.
But lawmakers from both parties have raised questions about unilateral actions by the president to waive or delay various provisions of the law. J. Mark Iwry, deputy assistant Treasury secretary for health policy, said the administration had broad ''authority to grant transition relief'' under a section of the Internal Revenue Code that directs the Treasury secretary to ''prescribe all needful rules and regulations for the enforcement'' of tax obligations. This authority has often been used to postpone the application of new laws that would cause ''unreasonable administrative burdens or costs'' to taxpayers, Mr. Iwry said.
Under the law, larger employers may be subject to tax penalties if they do not offer ''minimum essential coverage'' to employees who work at least 30 hours a week, on average.
Larger companies have, for many years, been more likely to offer coverage than smaller ones.
The Treasury said that companies with 50 to 99 employees accounted for 7 percent of the private sector work force, while businesses with 100 or more workers accounted for 66 percent. Most companies with 100 or more employees already offer health benefits to at least some of their workers. Small businesses with fewer than 50 employees account for nearly 28 percent of private sector employees, but 96 percent of all private employers, the Treasury said.
Paul M. Hamburger, a lawyer who advises employers at the Proskauer law firm, said: ''The bottom line is that Obamacare is not going away. The administration is providing another one-year delay, until 2016, for some employers. But they have to take the law seriously and figure out ways to comply. The administration did not provide the relief sought by employers in some high-turnover industries like restaurants and retail.''
In response to concerns expressed by lawmakers from both parties, the administration said that local government agencies would generally not have to provide health insurance to ''bona fide volunteers'' who work as firefighters or emergency medical technicians.
The administration said it was still trying to figure out how to count the hours worked by certain types of employees, including part-time college instructors who are paid for teaching a certain number of classes or courses. Until guidance is issued, Treasury officials said, colleges may assume that such ''adjunct faculty'' members spend 75 minutes a week outside the classroom, preparing lectures or grading examinations, for each hour teaching in the classroom.
Federal officials said they were also providing some relief to employers of seasonal employees. Those who normally work a half-year or less will generally not be considered full-time employees, the administration said.
URL: http://www.nytimes.com/2014/02/11/us/politics/health-insurance-enforcement-delayed-again-for-some-employers.html
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January 17, 2017 Tuesday 00:00 EST
The G.O.P.'s Health Care Death Spiral;
Op-Ed Contributor
BYLINE: J. B. SILVERS
SECTION: OPINION
LENGTH: 1002 words
HIGHLIGHT: A repeal-and-delay of Obamacare would be a "total disaster" for the individual insurance market.
Last week, President-elect Donald J. Trumpcalled Obamacare "a complete and total disaster," and pushed for a swift repeal of the Affordable Care Act and a replacement within weeks. But at the moment, there is no workable replacement. So what happens to the individual insurance market - whose problems did not start with the Affordable Care Act and will not be easily solved - when it is destabilized so dramatically?
From my point of view as a former health insurance company chief executive, "total disaster" would also describe any Republican repeal-and-delay plan. Although my former colleagues in the insurance industry are too cowed by the president-elect to say so, Republican insistence on repeal without having a meaningful replacement at the same time will drive most insurers out of the individual market and leave the 10 percent of Americans now covered by some aspect of the A.C.A. without coverage - especially if Medicaid expansion is rolled back as well.
The proportion of uninsured Americans, which has dropped to less than 9 percent, the lowest on record, will at least double. By April, when filings from insurance company plans and premiums for 2018 are due, there will be a sizable exit - of insurers running away from the greatly increased and unpredictable risk and of individuals not able to afford insurance without the subsidies.
Of course, the A.C.A. has a number of flaws, and repair is critical. But delay is not an option if the replacers really want to use private insurers to meet society's goals of access, affordability and quality in health care. All known Republican alternatives envision heavy reliance on the same insurers that are now ready to bolt and leave a total mess rather than a defective but repairable market.
After they leave, the damage will spread to doctors and hospitals, whose bad debt will skyrocket when patients miss copays and drop coverage while providers and hospitals still must continue care.
This is not speculation but based on my experience in the industry and as a member of the board of a public hospital that stands to lose substantial Medicaid payments if the state expansions are rolled back.
Let's go back for a moment to pre-Obamacare days. Why did insurers refuse to cover individuals with pre-existing conditions, cancel policies if customers used them too much, set high premiums for women and old people, and so forth? These tools were the only way to limit risk when insurers didn't have a ready-made pool of sufficient size to balance the sick and well as employer-sponsored plans do.
Refusing coverage and the like was good business, but it did not serve small businesses, the self-employed or other people unable to get the insurance they wanted. The Obamacare exchanges tried to fix this by requiring everyone to join the pool, providing premium and cost-sharing subsidies geared to income (the "affordable" in the law's name) and limiting risk to insurers to entice them to offer policies.
It's a tricky business to fine-tune a market and encourage buyers and sellers to do the right thing - both providing access to individuals in need and encouraging enough insurers to join to make competition work. But George W. Bush, with some bipartisan support, did it not so long ago with the Medicare drug plans.
But unfortunately, the A.C.A. law created by Democrats in Congress had several big flaws. Pricing restrictions - which essentially mandated that insurers overcharge younger customers relative to older ones - created the wrong incentives, and so too many older, sicker individuals joined, and younger, healthy people were discouraged.
This was compounded by a Republican Congress that reneged on its promise to help insurers in the first years of the program by limiting risk. Congress allowed only 12 percent of the backup that was promised to companies when they set their premiums on the Obamacare exchanges. This ramped up their risk dramatically.
If you're wondering why insurers substantially increased premiums for this year, even far beyond the underlying health care inflation rate - now at around 4 percent - this shell game with risk is your answer.
Ultimately, if the risk is too high, exit is inevitable. That is what my top-rated plan, Qualchoice, did in Ohio in the late 1990s to stem multimillion-dollar losses from its participation in the Medicaid Advantage managed care program. It's also what United Healthcare did and most others will do this spring when faced with the uncertainty of delay.
Finally, none of the participants, in government or business, want to recognize that in many parts of the country, only one insurer or a highly consolidated health system dominates, which eliminates meaningful competition and choice.
Since 2010, Republicans have made political hay by demonizing the mandate to buy insurance, subsidies to make it affordable and taxes on employers, suppliers, insurers and especially the wealthy to finance it. But now they own the problem and must fix it or do something better.
Obamacare, or any plan that replaces it that is reliant on private insurers and individual enrollment, will succeed only under the following conditions: a meaningful incentive to purchase insurance (the individual mandate or equivalent); help to make it affordable; risk reduction for insurers to stabilize premiums; and enough funding to pay for it all.
If any replacement plan doesn't include these elements, private insurance will revert to the chaos of the pre-A.C.A. market. In business, managing risk is important; in insurance, it is everything. Whoever plays games with it - knowingly or inadvertently - is playing with fire.
If we manage this risk badly through repeal and delay, the damage to insurers, individuals, hospitals and professionals will be profound.
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J. B. Silvers is a professor of health finance at the Weatherhead School of Management at Case Western Reserve University.
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October 6, 2013 Sunday
Late Edition - Final
Sunday Dialogue: A Disillusioned Citizenry
SECTION: Section SR; Column 0; Editorial Desk; LETTERS; Pg. 2
LENGTH: 1913 words
Readers discuss what has bred public distrust of government.
To the Editor:
According to a recent Gallup poll, only 42 percent of Americans have faith that government is operating in their interests on domestic matters, and 49 percent trust the government on international matters. I believe that this is a key reason that many Americans are opposed, wrongly in my opinion, to the Affordable Care Act.
Vietnam turned a whole generation sour on government. My brother went over a Goldwater conservative and returned as an anarchist war protester. But we did not learn. The Iraq war was totally unnecessary and cost thousands of American lives and will eventually cost trillions of dollars. It's not hard to understand why Americans are skeptical of unilateral intervention in Syria.
Other more recent government actions have bred public mistrust. For example, very little was done by Congress to control Wall Street after the economic collapse in 2008. Many called for charges to be brought against financial criminals and stricter banking laws to prevent a future meltdown. What they got was a watered down, ineffective Dodd-Frank Act. I could cite many other examples, including Watergate and the current Congressional impasse that led to a government shutdown. The point is that Americans are generally fed up with what they see as government incompetence and lying.
In my view, this is why Americans do not believe that the Affordable Care Act is being enacted to help them. They have been told time and time again that government actions are in their interests, only to find out that they are not.
Unfortunately, this time the program in question addresses a real problem, lack of insurance. But the public will not listen.
JACK BERNARD Monticello, Ga., Oct. 1, 2013
The writer is a retired health care executive and former Republican Party chairman of Jasper County.
Readers React
Americans don't distrust the government. Republicans trust the parts of it run by their party, just as Democrats trust the parts run by theirs. What we distrust is those lowdown, back-stabbing snakes in the grass who belong to the other party.
Ancient Athens was able to produce a functional democracy only after its leaders outlawed the city's traditional kin-based tribes, forging the city's people into a single nation. But the leaders of our parties do everything they can to destroy our sense of common goals and common values by dividing us into tribes.
Self-government is a difficult thing. It will always be subject to the influence of selfishly motivated interests, as well as well-meaning but mistaken theories and even outright incompetence.
But it isn't the government's mistakes, no matter how often they're repeated, that make people distrust it. It's our distrust of our fellow citizens that we see reflected in our negative attitudes about the government.
DAVID RAINES Lunenburg, Mass., Oct. 2, 2013
Vietnam and Iraq were simply bad policy decisions, but there is something more insidious and perhaps far more dangerous going on today. Routine use of filibusters, attacks on voting rights, challenges to the legitimacy of the president, brinkmanship with the debt ceiling -- these and other tactics add up to an attack by right-wing extremists on the infrastructure of our democracy.
Loss of faith in government is not just a byproduct of these tactics; it's the primary objective, with the ultimate goal being dismantlement.
As imperfect as the Affordable Care Act is, it's the best solution that could have passed Congress during President Obama's first term. With bipartisan cooperation it could become far better, but the insurgents will apparently not stop until it has been destroyed.
ROBERT Z. OKSNER Winter Park, Fla., Oct. 2, 2013
Why should we trust a government that by any measure is inept, wasteful and corrupt? We can easily see the genesis of the financial meltdown in misguided government policy, yet not one elected official is brought to account. Why should we embrace the Affordable Care Act, 2,700 pages of mass confusion enacted with legislative legerdemain?
To underline this distrust one need only to look at the role of outside money and the perverse role it plays in our electoral system.
BILL BRENNAN Novato, Calif., Oct. 2, 2013
May I suggest that Americans distrust their government because they believe that it no longer serves the public interest? ''Washington gridlock'' is just an elaborate charade. Both political parties serve special interests: oligarch banks, oil and gas producers, defense contractors, insurance companies and so on. These special interests, in turn, finance Congressional and presidential campaigns and provide well-paying jobs and lobbying fees to elected officials and their staffers when they leave the public sector.
As Mr. Bernard points out, the Affordable Care Act is supposed to provide health care coverage for Americans who cannot afford it. The act is also designed to provide tens of millions of new customers to private health care insurers.
The act was written primarily by staffers of the Senate Finance Committee, whose chairman, Senator Max Baucus, had proponents of single-payer health care forcibly removed from Finance Committee hearings.
The only way I can see for making government more responsive to the needs of the American public, and thus restoring their trust in government, is through a series of constitutional amendments providing for: Congressional term limits; only public funding for Congressional and presidential campaigns; limiting these campaigns to 60 days; and square-shaped Congressional districts to prevent gerrymandering.
Call me cynical, but I believe that entrenched special interests will prevent such amendments from ever coming about.
JEFFREY H. SPIEGLER Cleveland, Oct. 2, 2013
Mr. Bernard has given numerous examples of government actions that have bred distrust. Are Americans fed up with government incompetence and lying? Absolutely. But the problem is fixable.
If it's a good idea, sell it. Convincingly. With solid facts, evidence and logic. Whether it's a war in the Mideast or a sweeping change to America's health care system, a strong case needs to be made to the American people for trust to be established.
Treat the public like a trial jury; even a rookie lawyer would be embarrassed presenting the weaker-than-weak case about Iraq and weapons of mass destruction that Colin Powell took to the United Nations. Affordable Care Act? Lots of noise, but no coherent and convincing case was ever made to the American people.
I agree with Mr. Bernard that the days when government leaders could get away with ''trust us'' are over. We want to be convinced, and expect our leaders to do an effective job of convincing us. If they can't, the chances are pretty good that the public will quickly decide that it's a bad idea.
GEORGE PETERNEL Arlington Heights, Ill., Oct. 2, 2013
As I read book after book, essay after essay, describing and analyzing the death of American consensus, I come back to wartime, economic and political disasters that account for our self-doubt and reluctance to trust government.
We did not win militarily in Korea, were defeated in Vietnam, and failed to free Iraq or Afghanistan of strife. We failed to lift entire generations above drugs and crime. Our Supreme Court elevated the wrong man to the presidency and unleashed the wealth of plutocrats into our election process. Millions lost their homes, jobs and hope because of our financial giants. Finally, we elected an introverted scholarly moderate to the presidency when we needed a miracle worker.
Why would we not be depressed and distrustful?
PAUL R. COOPER Yellow Springs, Ohio, Oct. 2, 2013
Mr. Bernard has identified the problem, but not the solution. Like his brother, I was a Goldwater activist before the Vietnam War who became antiwar. Distrust is justified. Anarchy (another name for unbridled libertarianism) is not.
The solution is to elect people who want government to work, not people who simply want to tear government down.
DAN MABBUTT Springdale, Utah, Oct. 2, 2013
Wars, scandals and financial disasters can certainly make Washington look bad, but to find reasons for doubting its ability to manage entitlements, we need look no further than Social Security and Medicare. We've known for decades that longer life spans and low birthrates would eventually wreck these programs, without reforms, and what have our leaders offered? The World Cup of can kicking.
A government that refers to its own tax and spending policies as unsustainable (as ours has) and then presents the public with an expensive new entitlement can expect a lot of distrust, if not outright bewilderment.
MICHAEL SMITH Cynthiana, Ky., Oct. 3, 2013
Americans might trust the government more if they fully appreciated the foundation it creates for our economic well-being. Across the economy, it builds and maintains the infrastructure that makes private business possible, often in ways that escape public notice. Try to imagine the computer industry without the Internet, telecommunications without satellites, or automobile manufacturing without Interstate highways, all of them government creations.
A government foundation is nowhere more important than in health care. The pharmaceutical industry, for example, relies on basic biomedical research sponsored by the National Institutes of Health for its very existence. And new health care industries, as yet unimagined, will grow and thrive based on an expanded insurance infrastructure created by the Affordable Care Act.
The government's failings are painfully visible, while we take many of its successes for granted. Our general mistrust threatens the very engine of our prosperity.
ROBERT I. FIELD Philadelphia, Oct. 2, 2013
The writer is a professor of law and public health at Drexel University and the author of ''Mother of Invention: How the Government Created 'Free-Market' Health Care.''
The Writer Responds
Apparently, my statements about the public's distrust of government have struck a nerve.
As a former elected official, I agree with Mr. Brennan's comments about the ''perverse role'' of political contributions in our electoral system. The problem is that both parties are married to the lobbyists and, to quote Mr. Raines, the ''selfishly motivated interests'' that they represent.
In my opinion, that is why President Obama went with national Romneycare versus Medicare for all (my preference), which he once strongly advocated. Big Pharma, large insurance companies and major medical associations all backed the Affordable Care Act. It was in their financial interest to do so, and Mr. Obama needed their clout to get quasi-universal health insurance passed.
Mr. Cooper makes a particularly salient point: Mr. Obama is ''an introverted scholarly moderate,'' not someone likely to bring about major change. He naïvely decided to advocate a private-sector insurance solution, originally conceived by the conservative Heritage Foundation, in hopes that the Republican Party would miraculously find common ground with Democrats.
Anti-Obamacare rhetoric was a major factor in wiping out what was left of the ''blue dog'' Democrats and ushering in politicians who ''want to tear government down,'' per Mr. Mabbutt. I agree with him that the solution is to elect people who can work with the other side. But that will only happen if our fragmented electorate votes the radicals out, a much harder task after the partisan 2010 redistricting.
JACK BERNARD Monticello, Ga., Oct. 3, 2013
URL: http://www.nytimes.com/2013/10/06/opinion/sunday/sunday-dialogue-a-disillusioned-citizenry.html
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September 26, 2013 Thursday
6 Q's About the News | Senate Votes to Move Forward on Budget Debate
BYLINE: MICHAEL GONCHAR
SECTION: EDUCATION
LENGTH: 220 words
HIGHLIGHT: The article describes Mr. Cruz as “a lightning rod, a hero to conservative activists, a rogue to others in both parties.” What do you think about Mr. Cruz and his actions?
In "After 21-Hour Cruz Speech, Senate Votes to Take Up Budget," Jonathan Weisman writes about the drama unfolding in Congress this week as the Senate and House inch closer to a possible government shutdown.
WHO led a "verbal assault" on the Affordable Care Act on Tuesday and Wednesday?
HOW long did his marathon session last?
WHY did he speak for so long? WHY did he stop speaking?
WHEN does the health care law begin enrolling uninsured Americans?
WHAT decision will Congress make between Wednesday and Oct. 1?
WHAT two options might Speaker John A. Boehner have to choose between, starting this weekend?
HOW did Senator John McCain respond in his "blistering speech"?
WHAT book did Mr. Cruz read in the middle of his marathon speech?
For Higher-Order Thinking
The article describes Mr. Cruz as "a lightning rod, a hero to conservative activists, a rogue to others in both parties." WHAT do you think about Mr. Cruz and his actions?
WHAT do you think about Mr. McCain's remarks?
Are you worried that Congress will not be able to pass a spending bill and we will face a government shutdown? WHY?
A Landmark Bill
Senate to Hold Full Debate on Gun Legislation
Watershed: Teaching About Gun Control After Newtown
Supreme Court Rules on Health Care
Before the Law: Understanding the Supreme Court Case on the Affordable Care Act
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The New York Times
April 2, 2017 Sunday
Late Edition - Final
Obamacare Will Outlast the Republicans
BYLINE: By DONALD M. BERWICK.
Donald M. Berwick, a senior fellow at the Institute for Healthcare Improvement, ran the Centers for Medicare and Medicaid Services from July 2010 to December 2011.
SECTION: Section SR; Column 0; Sunday Review Desk; OPINION; Pg. 9
LENGTH: 1053 words
What will Paul Ryan and the Trump administration do now that they have failed to repeal Obamacare? They'll try to sabotage it.
After their legislative debacle, they said they would let Obamacare explode on its own, after which, they hope, the Democrats will come crawling to them, pleading for a new plan.
''I'm open to that,'' President Trump announced.
But Republicans, who have tried for years to stop the government from expanding health care coverage, will not wait passively for a disaster to happen.
My experience as President Barack Obama's administrator of the Centers for Medicare and Medicaid Services should serve as a warning. From Day 1, Republicans did what they could to weaken the Affordable Care Act. While we worked to make it easier for eligible people to apply for Medicaid, Republicans favored rules that made enrollment harder. They cut budgets for implementing Obamacare provisions, like modernized data systems.
And they opposed outreach to educate the public. When we sent beneficiaries a brochure about their new options, Mitch McConnell, then the Senate minority leader, called it ''propaganda.'' Meanwhile, they spread misinformation, claiming, for example, that premiums were soaring everywhere and that doctors were dropping Medicare, when in fact, overall premium increases were historically low and Medicare patients experienced no discernible change in their access to doctors.
Now that the Republicans are in control of both elected branches of government, they are in a position to undermine the Affordable Care Act from within -- and then to blame the law, rather than their own sabotage, for its failure.
Congress, the Trump administration and Tom Price, the secretary of health and human services, could do a lot of damage without overturning the law. This has already begun. Early this year, President Trump stopped advertising aimed at persuading healthy young people to sign up for coverage -- a perfect way to cause the ''death spiral'' Republicans are so fond of predicting.
Now, they can starve the agencies that have to administer the law, making it hard for them to do their jobs. They can make it riskier for insurance companies to participate and can decrease enforcement of requirements that policies cover a basic set of benefits. The new administrator of Medicare and Medicaid, Seema Verma, favors giving states waivers to avoid some of the law's provisions, weakening coverage and increasing out-of-pocket costs. Under President Obama, my agency carefully reviewed any state-level changes in Medicaid benefits and marketplace policies, but far less diligence is likely now.
They could also stop learning about best practices from different states' approaches. In Obamacare's first seven years, some states, like Massachusetts, Arkansas and California, have come up with creative ways to keep premium increases down by encouraging better care and providing incentives for healthy people to sign up. Others, like Arizona, Oklahoma and Tennessee, have been more passive and have seen much higher increases. Significantly, states that expanded Medicaid have, on average, kept premiums down, because many expensive patients were covered by Medicaid instead of having to enter the marketplace's high-risk pools.
The Affordable Care Act established the Center for Medicare and Medicaid Innovation to support trials of ''new models'' of care and payment, and it gave the secretary of health and human services the authority to spread those models if they were proved effective. But the Trump administration shows little interest in learning from what works. It has already stopped the expansion of a new way of paying for hip and knee replacement surgery that has been shown to keep costs down and quality up.
In their charge to repeal and replace, Mr. Ryan and company talked only about states that have not done well, ignoring the lessons from those that have succeeded. We can expect that erosive messaging to continue.
Fortunately for the millions of Americans who get their health coverage through the Affordable Care Act, the Republicans are probably going to fail. The program is much stronger than they'd like us to believe. It is not in a death spiral and, if left alone, will continue to meet patients' needs for the foreseeable future.
But it does need improvement. The individual and small-group market -- for those who lack employer-sponsored insurance, Medicare or Medicaid -- has indeed been vulnerable to ''adverse selection,'' in which healthy people stay out and sick people stay in, causing some premiums to go up. This is a significant but reparable defect, and some states have already fixed it. California used extensive marketing to encourage healthy young adults to get insurance and worked with health plans to provide generous benefits at fair prices. Federal support could help other states follow suit.
The law's transparency provisions, intended to help insurers and patients learn more easily where prices are lower and quality is higher, also need better enforcement and more support. We need to reduce the price of access to such data (while strictly protecting patient privacy).
Finally, insurers are nervous. Because they had difficulty estimating their risks under the law, there were provisions that protected them from miscalculations in the first three years. This worked, lowering premiums by as much as 14 percent. That protection has now been phased out, but help is still possible. Alaska set up an innovative state reinsurance fund to cushion insurance companies from extremely high-cost cases, keeping them from having to impose whipsawing premiums on customers.
Unfortunately, it's unlikely that any of these fixes will happen anytime under Republicans, who have already staked their reputation on the prediction that Obamacare will soon ''explode.'' It is hard to imagine that they won't try their best to make that dire prediction a reality.
Will they succeed? Probably not. The law does too much good for too many people for doctrine to override evidence. But the Affordable Care Act's opponents have been undermining it for years, and we, its defenders, drop our guard at our peril.
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URL: http://www.nytimes.com/2017/04/01/opinion/sunday/obamacare-can-survive-trump.html
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The New York Times
May 11, 2012 Friday
Late Edition - Final
Christie Vetoes Insurance Exchange, Citing Supreme Court Case on Health Care Law
BYLINE: By KATE ZERNIKE
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 26
LENGTH: 877 words
In a swipe at President Obama's signature health care legislation, Gov. Chris Christie of New Jersey vetoed on Thursday an online marketplace that the Legislature created to help residents and small businesses buy health insurance.
The Affordable Care Act, the federal law passed in 2010, requires most Americans to have health insurance and mandates states to have health care benefits exchanges to help them buy it. With the Supreme Court debating whether the health care law is constitutional, Mr. Christie said in his veto message that the exchange, approved in March, was ''premature'' and could impose ''unnecessary obligations upon the state's citizens.''
''Indeed, the very constitutionality of the Affordable Care Act is cloaked in uncertainty, as both the individual mandate to procure health insurance as well as the jurisdictional mandate to establish an exchange may not survive scrutiny by the Supreme Court,'' he wrote.
''Because it is not known whether the Affordable Care Act will remain, in whole or in part, it would be imprudent for New Jersey now to create an exchange before these critical threshold issues are decided with finality by the court,'' he added.
Mr. Christie was the second governor to veto such a law, following Gov. Susana Martinez of New Mexico, who is also a Republican. In New York, Gov. Andrew M. Cuomo, a Democrat, took the opposite tack last month: after the Legislature declined to create an exchange, he established one by executive order.
Ultimately, Mr. Christie's veto is largely symbolic. The federal law requires states to offer health care exchanges by January 2014, but provides that Washington will step in to administer them in states that fail to make progress by January 2013. In either case, the state pays to set up the health care exchange, but states that fail to create the exchanges lose the ability to oversee them.
Democratic lawmakers accused the governor of playing politics with the needs of the most vulnerable residents.
''It's clear from his actions that he is more focused on winning praise from national Republican pundits than protecting New Jersey families' access to health care,'' said Assemblyman Louis Greenwald of Camden, the leader of the Democratic majority in the State Assembly.
The Democrats warned that the governor's veto would leave the state scrambling to comply with the federal law and could jeopardize future grant money. New Jersey had already received two federal grants, totaling $8.7 million, to prepare the exchange.
Assemblyman Herb Conaway of Burlington, a doctor who was the lead sponsor of the legislation in the chamber, said the governor was sending a message that ''he doesn't care'' about the 1.3 million state residents without health insurance.
''By vetoing this bill, Governor Christie has failed New Jersey's uninsured residents, hurt New Jersey's chances of fully benefiting from federal health care reform and ignored the need to provide relief to hospitals for uncompensated care,'' Dr. Conaway, a Democrat, said.
Democrats in the Legislature had billed the exchange as one-stop shopping for people or businesses seeking health insurance, allowing consumers to compare the benefits and the costs of participating plans.
The Web site it proposed would have also allowed people to apply for tax credits or other subsidies toward the cost of insurance.
In his veto message, the governor said he was concerned about the potential costs of the exchange.
The bill passed by the Legislature would have established a Medicaid-like plan for people with incomes between 133 percent and 200 percent of the federal poverty level. Mr. Christie argued that it was unclear whether there would be federal financing to support such a plan.
In addition, he argued that the mechanism the bill set up to approve plans would limit the number of companies that could participate, which he said would both reduce options and increase costs.
''In all, with basic issues regarding the future of the Affordable Care Act unresolved, it is impossible to know whether this legislation best suits the interests and needs of all New Jerseyans who will be required to finance these policy choices,'' the governor wrote.
Mr. Christie said that if the federal law was upheld, he would oversee the state's compliance ''in a responsible and cost-effective manner.''
But while the governor cited the cost of putting the exchange into effect, Democrats in Washington and Trenton argued that the bigger cost was allowing so many residents to remain uninsured.
''New Jersey taxpayers are on the hook every time someone without coverage shows up in an emergency room, whether it's for life-threatening treatment or routine medical care,'' United States Senator Robert Menendez said.
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The New York Times
January 21, 2017 Saturday
Late Edition - Final
Trump Issues Executive Order to Scale Back Parts of Health Care Law
BYLINE: By JULIE HIRSCHFELD DAVIS and ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 20
LENGTH: 814 words
WASHINGTON -- In his first executive order, President Trump on Friday directed government agencies to scale back as many aspects of the Affordable Care Act as possible, moving within hours of being sworn in to fulfill his pledge to eviscerate Barack Obama's signature health care law.
The one-page order, which Mr. Trump signed in a hastily arranged Oval Office ceremony shortly before departing for the inaugural balls, gave no specifics about which aspects of the law it was targeting. But its broad language gave federal agencies wide latitude to change, delay or waive provisions of the law that they deemed overly costly for insurers, drug makers, doctors, patients or states, suggesting that it could have wide-ranging impact, and essentially allowing the dismantling of the law to begin even before Congress moves to repeal it.
The order states what Mr. Trump made clear during his campaign: that it is his administration's policy to seek the ''prompt repeal'' of the law, which has come to be known as Obamacare. But he and Republicans on Capitol Hill have not yet devised a replacement, making such action unlikely in the immediate term.
''In the meantime,'' the order said, ''pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act, and prepare to afford the states more flexibility and control to create a more free and open health care market.''
The order has symbolic as well as substantive significance, allowing Mr. Trump to claim he acted immediately to do away with a health care law he has repeatedly called disastrous, even while it remains in place and he navigates the politically perilous process of repealing and replacing it.
Using the phrase ''to the maximum extent permitted by law,'' the order directs federal agencies to move decisively to implement changes, including granting flexibility that insurers and states had long implored the Obama administration to provide.
It also instructs them to work to create a system that allows the sale of health insurance across state lines, which Republicans have long proposed as the centerpiece of an alternative to the law.
''This action demonstrates that President Trump is committed to fixing the damage caused by Obamacare as soon as possible,'' said Senator John Barrasso, Republican of Wyoming.
The order does not direct the Department of Health and Human Services to ease any particular aspect of the 2010 law, but it could result in a substantial weakening of one of its central features: the so-called ''individual mandate'' that requires most Americans to have health insurance or pay a tax penalty.
While the Obama administration allowed ''hardship exemptions'' to the mandate, the Trump administration could conceivably interpret the requirement in a more lenient way, so that more people would not be penalized.
Likewise, federal officials could be more receptive to state requests for waivers under Medicaid, the federal-state program that covers more than 70 million low-income people. A number of Republican governors and state legislators would like to charge higher premiums or co-payments than are now allowed. Some states want to provide a less generous, less expensive package of benefits, or require some able-bodied adults to engage in work activities as a condition of receiving Medicaid.
Still, while Mr. Trump's directive allows officials to take steps that increase costs for consumers, that result is not inevitable. Indeed, the order says officials should try to reduce costs and burdens on consumers.
Over the last six years, insurance company executives have bitterly complained that federal insurance regulations were extremely prescriptive and onerous. By relaxing some of those rules, the Trump administration could make the individual insurance market more attractive to insurers. And insurers might then be more willing to stay in or return to the public marketplaces established under the Affordable Care Act.
In the last year, a number of insurers have dropped out of those markets, leaving consumers with fewer health plans to choose from.
House Republican leaders recently asked governors for recommendations on health policy, and governors from both parties said the federal government should scale back its regulation of health insurance.
Gov. Bill Haslam of Tennessee, a Republican, said this month that federal officials should ''reconsider the premise that health insurance public policy should be directed from Washington.'' He said that federal rules for setting insurance rates and defining ''essential health benefits'' should be more flexible.
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URL: http://www.nytimes.com/2017/01/20/us/politics/trump-executive-order-obamacare.html
LOAD-DATE: January 21, 2017
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GRAPHIC: PHOTO: President Trump signing his first executive order on Friday, on the Affordable Care Act. Its broad language gave wide latitude to change, delay or waive provisions. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)
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The New York Times Blogs
(The Learning Network)
October 2, 2013 Wednesday
6 Q's About the News | Government Shutdown Begins as Health Insurance Exchanges Open
BYLINE: MICHAEL GONCHAR
SECTION: EDUCATION
LENGTH: 279 words
HIGHLIGHT: What are Republicans insisting as part of their budget negotiations with Congressional Democrats and President Obama?
In "House G.O.P. Stands Firm on Shutdown, but Dissent Grows," Jeremy W. Peters writes about the politics of the first day of the government shutdown.
WHAT are Republicans insisting as part of their budget negotiations with Congressional Democrats and President Obama?
HOW did President Obama respond to Republican demands?
WHAT plan are House leaders presenting to their rank and file as a strategy to lessen the impact of the shutdown while trying to pressure Democrats to roll back part or all of the Affordable Care Act?
WHAT are some of the tangible signs of the shutdown that the American public is seeing on the Internet and television?
WHO do Republicans blame for the shutdown?
WHY isn't Speaker John A. Boehner letting the House vote on a bill that would finance the government without making any changes to the health care law?
WHEN was the first day of enrollment in the new health insurance exchanges that will become the backbone of Obamacare?
HOW was Tuesday's rollout of the online insurance markets at the heart of President Obama's health care law, according to this article
For Higher-Order Thinking
HOW do you feel about the government shutdown? WHY?
HOW do you feel about House Republicans trying to delay or defund the Affordable Care Act as part of their negotiations for ending the government shutdown? Do you think their strategy is justified?
6 Q's About the News | Budget Standoff Leads to Government Shutdown
Is It Principled, or Irresponsible, for Politicians to Threaten a Shutdown?
6 Q's About the News | Senate Votes to Move Forward on Budget Debate
Senate to Hold Full Debate on Gun Legislation
Watershed: Teaching About Gun Control After Newtown
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The New York Times Blogs
(The Learning Network)
October 2, 2013 Wednesday
6 Q's About the News | Government Shutdown Begins as Health Insurance Exchanges Open
BYLINE: MICHAEL GONCHAR
SECTION: EDUCATION
LENGTH: 279 words
HIGHLIGHT: What are Republicans insisting as part of their budget negotiations with Congressional Democrats and President Obama?
In "House G.O.P. Stands Firm on Shutdown, but Dissent Grows," Jeremy W. Peters writes about the politics of the first day of the government shutdown.
WHAT are Republicans insisting as part of their budget negotiations with Congressional Democrats and President Obama?
HOW did President Obama respond to Republican demands?
WHAT plan are House leaders presenting to their rank and file as a strategy to lessen the impact of the shutdown while trying to pressure Democrats to roll back part or all of the Affordable Care Act?
WHAT are some of the tangible signs of the shutdown that the American public is seeing on the Internet and television?
WHO do Republicans blame for the shutdown?
WHY isn't Speaker John A. Boehner letting the House vote on a bill that would finance the government without making any changes to the health care law?
WHEN was the first day of enrollment in the new health insurance exchanges that will become the backbone of Obamacare?
HOW was Tuesday's rollout of the online insurance markets at the heart of President Obama's health care law, according to this article
For Higher-Order Thinking
HOW do you feel about the government shutdown? WHY?
HOW do you feel about House Republicans trying to delay or defund the Affordable Care Act as part of their negotiations for ending the government shutdown? Do you think their strategy is justified?
6 Q's About the News | Budget Standoff Leads to Government Shutdown
Is It Principled, or Irresponsible, for Politicians to Threaten a Shutdown?
6 Q's About the News | Senate Votes to Move Forward on Budget Debate
Senate to Hold Full Debate on Gun Legislation
Watershed: Teaching About Gun Control After Newtown
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The New York Times Blogs
(The Learning Network)
October 2, 2013 Wednesday
6 Q's About the News | Government Shutdown Begins as Health Insurance Exchanges Open
BYLINE: MICHAEL GONCHAR
SECTION: EDUCATION
LENGTH: 279 words
HIGHLIGHT: What are Republicans insisting as part of their budget negotiations with Congressional Democrats and President Obama?
In "House G.O.P. Stands Firm on Shutdown, but Dissent Grows," Jeremy W. Peters writes about the politics of the first day of the government shutdown.
WHAT are Republicans insisting as part of their budget negotiations with Congressional Democrats and President Obama?
HOW did President Obama respond to Republican demands?
WHAT plan are House leaders presenting to their rank and file as a strategy to lessen the impact of the shutdown while trying to pressure Democrats to roll back part or all of the Affordable Care Act?
WHAT are some of the tangible signs of the shutdown that the American public is seeing on the Internet and television?
WHO do Republicans blame for the shutdown?
WHY isn't Speaker John A. Boehner letting the House vote on a bill that would finance the government without making any changes to the health care law?
WHEN was the first day of enrollment in the new health insurance exchanges that will become the backbone of Obamacare?
HOW was Tuesday's rollout of the online insurance markets at the heart of President Obama's health care law, according to this article
For Higher-Order Thinking
HOW do you feel about the government shutdown? WHY?
HOW do you feel about House Republicans trying to delay or defund the Affordable Care Act as part of their negotiations for ending the government shutdown? Do you think their strategy is justified?
6 Q's About the News | Budget Standoff Leads to Government Shutdown
Is It Principled, or Irresponsible, for Politicians to Threaten a Shutdown?
6 Q's About the News | Senate Votes to Move Forward on Budget Debate
Senate to Hold Full Debate on Gun Legislation
Watershed: Teaching About Gun Control After Newtown
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The New York Times
October 21, 2013 Monday
Late Edition - Final
Specialists See Weeks of Work On Health Site
BYLINE: By SHARON LaFRANIERE, IAN AUSTEN and ROBERT PEAR; Sharon LaFraniere reported from New York, Ian Austen from Ottawa, and Robert Pear from Washington. Michael D. Shear contributed reporting from Washington, and Reed Abelson from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1291 words
Federal contractors have identified most of the main problems crippling President Obama's online health insurance marketplace, but the administration has been slow to issue orders for fixing those flaws, and some contractors worry that the system may be weeks away from operating smoothly, people close to the project say.
Administration officials approached the contractors last week to see if they could perform the necessary repairs and reboot the system by Nov. 1. However, that goal struck many contractors as unrealistic, at least for major components of the system. Some specialists working on the project said the online system required such extensive repairs that it might not operate smoothly until after the Dec. 15 deadline for people to sign up for coverage starting in January, although that view is not universally shared.
In interviews, experts said the technological problems of the site went far beyond the roadblocks to creating accounts that continue to prevent legions of users from even registering. Indeed, several said, the login problems, though vexing to consumers, may be the easiest to solve. One specialist said that as many as five million lines of software code may need to be rewritten before the Web site runs properly.
''The account creation and registration problems are masking the problems that will happen later,'' said one person involved in the repair effort.
The scrambling underscores the pressures on the administration to fix what is widely viewed as the president's biggest domestic achievement. Millions of Americans have spent countless hours in frustration trying to use the federal Web site, healthcare.gov, and its extensive problems have become a political crisis for the administration, providing new opportunities for Republicans who want to roll back the health care law.
Over the weekend, officials sought to counter pronouncements of failure by announcing that almost half a million people have submitted applications for health insurance through the federal and state marketplaces, about half of them through state exchanges. But officials declined to say how many have actually enrolled in insurance plans, and executives from insurance companies, which receive the enrollment files from the government, say their numbers have been low. The enrollment period ends March 31; those who go without coverage may be subject to fines.
On Monday, Mr. Obama will host a Rose Garden event with people who have successfully enrolled in the health care exchanges. White House aides said he will acknowledge that the technical problems are ''inexcusable,'' but will note, as one adviser said, that the health care law is ''more than a Web site.''
''There's great demand for the affordable health care coverage made available by the A.C.A.,'' Jennifer Palmieri, the White House communications director, said Sunday, referring to the Affordable Care Act. ''The challenge for all of us -- the state and federal governments and contractors alike -- is to make sure the American people can access it simply. We won't rest until they can.''
Senior officials took to the Sunday talk shows to defend the Affordable Care Act, and Republicans countered them. Senator Marco Rubio, Republican of Florida, said on ''Fox News Sunday'' that the early failures do not bode well for the rest of the health care law, adding: ''In the 21st century, setting up a Web site where people can go on and buy something is not that complicated.''
One major problem slowing repairs, people close to the program say, is that the Centers for Medicare and Medicaid Services, the federal agency in charge of the exchange, is responsible for making sure that the separately designed databases and pieces of software from 55 contractors work together. It is not common for a federal agency to assume that role, and numerous people involved in the project said the agency did not have the expertise to do the job and did not fully understand what it entailed.
The people close to the project spoke on the condition of anonymity because they were not authorized to discuss the system's problems.
Administration officials have been debating whether to designate one or more companies as the quarterback for information technology work on the federal exchange, a complex project that has cost more than $400 million.
Communications between the administration and contractors improved over the weekend as the Centers for Medicare and Medicaid Services began negotiating agreements with contractors on responsibility and deadlines for repairs, people involved in the project say. They hope to have a plan before a Congressional hearing set for Thursday.
''The issue right now is between C.M.S. and the White House,'' a specialist said Friday before communications improved. ''Everybody sits and waits and the meter runs.''
A part of the system, hidden from users, draws data from several federal and state databases to determine if consumers qualify for coverage and then calculates the subsidies for which they may be eligible. Another part of the system sends enrollment data to insurers. Several people involved in the project say that problems like those of the last three weeks are not uncommon when software from several companies is combined into a large, complex system.
Insurance executives said in interviews that they were frustrated because they did not know the government's plan or schedule for repairs. Insurers have found that the system provides them with incorrect information about some enrollees, repeatedly enrolls and cancels the enrollments of others, and simply loses the enrollments of still others.
Correcting those errors, specialists said, could require extensive rewriting of software code. Insurers said it could be weeks before their data and the government's could be reconciled.
Accurate enrollment data is essential. Even if consumers bypass the federal Web site and go directly to insurance companies to sign up for coverage, the Treasury Department will still need enrollment data to pay tens of billions of dollars in subsidies promised to insurers.
Confidential government documents show that some technical fixes have been made to the federal Web site, and specialists say the site is slowly improving.
Nevertheless, disarray has distinguished the project. In the last 10 months alone, government documents show, officials modified hardware and software requirements for the exchange seven times. It went live on Oct. 1 before the government and contractors had fully tested the complete system. Delays by the government in issuing specifications for the system reduced the time available for testing.
CGI Federal, a unit of the CGI Group, based in Montreal, has the biggest contract and is responsible for the architecture of major parts of the system, but not for its integration. Quality Software Services Inc., or Q.S.S.I., a unit of the UnitedHealth Group, developed the identity management system, another major component that allowed consumers to register and establish accounts.
The identity management system from Q.S.S.I., which also taps into government databases to retrieve users' personal information, was a particular source of trouble when the exchange opened. Change orders show that on Oct. 4 -- after millions of people had been trapped in technological loops trying merely to log in -- the government asked CGI to help it devise a new identity management system to replace the one provided by Q.S.S.I. But specialists said that approach was abandoned as too risky. Ultimately it was decided to fix the current identity system.
According to one specialist, the Web site contains about 500 million lines of software code. By comparison, a large bank's computer system is typically about one-fifth that size.
URL: http://www.nytimes.com/2013/10/21/us/insurance-site-seen-needing-weeks-to-fix.html
LOAD-DATE: October 21, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: Help navigating the federal online insurance exchange was available in Salt Lake City on Oct. 1. (PHOTOGRAPH BY FRANCISCO KJOLSETH/THE SALT LAKE TRIBUNE, VIA ASSOCIATED PRESS) (A15)
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The New York Times
July 30, 2015 Thursday
Late Edition - Final
As Medicare and Medicaid Turn 50, Use of Private Health Plans Surges
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 12
LENGTH: 1676 words
WASHINGTON -- As Medicare and Medicaid reach their 50th anniversary on Thursday, the two vast government programs that insure more than one-third of Americans are undergoing a transformation that none of their original architects foresaw: Private health insurance companies are playing a rapidly growing role in both.
More than 30 percent of the 55 million Medicare beneficiaries and well over half of the 66 million Medicaid beneficiaries are now in private health plans run by insurance companies like the UnitedHealth Group, Humana, Anthem and Centene. Enrollment has soared as the government, in an effort to control costs and improve care, pays private insurers to provide and coordinate medical services for more and more beneficiaries.
Although the programs remain highly popular with patients, skeptics question whether the use of private plans will save the government money in the long run and worry that the plans may skimp on care. But both programs served as foundations for the 2010 Affordable Care Act, which, like the newer versions of Medicare and Medicaid, uses a combination of government money and private insurance to provide coverage.
This week, the White House is using the half-century anniversary of Medicare and Medicaid to portray the Affordable Care Act as a logical extension of the two social insurance programs, which are part of the fabric of American life. Administration officials hope that President Obama's health care program will one day be as widely accepted as Medicare and Medicaid are now.
''The Affordable Care Act expanded Medicaid and built a model that helped fill some of the gaps between Medicare and Medicaid,'' Jason Furman, the chairman of the president's Council of Economic Advisers, said in an interview Wednesday. ''At the same time, it is rooted in the private sector and competition.''
When President Lyndon B. Johnson signed the bill creating Medicare and Medicaid on July 30, 1965, he made clear his ambitions for the programs: They would extend ''the miracle of healing to the old and to the poor.'' The legislation fulfilled decades of Democratic dreams, but, unlike the Affordable Care Act, it was passed with votes from a substantial number of Republicans.
The architects of Medicare and Medicaid, among them Wilbur J. Cohen and Robert M. Ball, had concluded that private insurance was out of reach for many older and low-income Americans, who could not obtain affordable coverage in the commercial market. At the time, Mr. Ball was the Social Security commissioner, and Mr. Cohen was a top official at the Department of Health, Education and Welfare, who later became secretary. Both men had been inspired by the New Deal and had worked for decades on Social Security.
''They believed that commercial health insurance had failed the elderly, and they wanted to replace it with social insurance, as a first step toward similar coverage for the rest of the population,'' said Theodore R. Marmor, a Yale professor and historian of Medicare.
In a secretly recorded telephone conversation in March 1965, Mr. Cohen described the Medicare bill that had just been approved by the House Ways and Means Committee. ''Quite frankly,'' Mr. Cohen told President Johnson, ''there's no longer any room for the private insurance companies to sell insurance policies for people over 65.''
In the original versions of Medicare and Medicaid, beneficiaries could go to any doctor who would take them, and the government would pay providers a fee for each service. By contrast, in private managed-care plans, beneficiaries use a network of doctors and hospitals, and the federal or state government pays insurers, which receive a fixed amount per member per month.
The original setup of Medicare and Medicaid began to change in the early 1980s after Congress and the Reagan administration created incentives for private insurers to contract with Medicare. Enrollment rose and fell as federal officials tinkered with reimbursement rates.
In the last decade, as private insurers accelerated their marketing of Medicare plans and baby boomers accustomed to managed care reached retirement age, enrollment in the private Medicare plans, called Medicare Advantage, surged. About 99 percent of beneficiaries now have the option to enroll in a Medicare Advantage plan, and the average beneficiary has a choice of more than a dozen plans.
In interviews, Medicare beneficiaries expressed a high degree of satisfaction with the original government-run program and the private alternatives, which include health maintenance organizations and other forms of managed care.
''For seniors on fixed income, an H.M.O. provides the best bang for the buck,'' said Ann E. Mason, 74, of Rochester.
Like many older Americans, she found that a Medicare Advantage plan offered better value than the combination of traditional Medicare and a supplementary insurance policy to fill gaps in Medicare, for expenses like co-payments and deductibles.
Ann C. Dorsey, 65, of Atlanta, qualified for Medicare several years ago after she developed a rare heart tumor and became disabled. She has invited insurance agents to her home to explain their plans and says she is pleased with her Cigna H.M.O.
''Anybody who doesn't look at Medicare Advantage is nuts,'' said Ms. Dorsey, who said she saved at least $1,000 a year because of lower out-of-pocket expenses. But, she said, before selecting a plan, beneficiaries need to do their homework, comparing benefits, physician rosters and prescription drug lists of different plans.
Yet even with managed care, big questions remain about how to finance Medicare and Medicaid for the next 50 years.
In Congress and in state legislatures, which help pay for Medicaid, the costs continue to cause anxiety. Under the Affordable Care Act, more than half the states have expanded eligibility for Medicaid, and state officials have enrolled most new beneficiaries in private plans.
In many states that expanded Medicaid, enrollment has far surpassed expectations, evidently because state officials underestimated the demand for insurance and the proportion of eligible low-income people who would sign up.
Michigan, for example, has signed up 600,000 people in 16 months -- more than it expected to enroll in five years. Nearly 80 percent of the new beneficiaries are in private managed-care plans.
Congress did reduce payments to private Medicare Advantage plans in the Affordable Care Act, to help offset the cost of the legislation, and insurers predicted that enrollment would decline. Instead, it has increased to 16.6 million people, from 11 million in 2010. The Congressional Budget Office predicts that the number will reach 30 million by 2025.
Experts say that private plans are not for everyone.
''Medicare Advantage plans are often more stingy with benefits,'' said Judith A. Stein, who has represented hundreds of beneficiaries as the executive director of the nonprofit Center for Medicare Advocacy. ''We have seen many cases in which people who are really sick cannot get coverage for nursing or therapy at home or in a skilled nursing facility -- coverage that they would be able to get if they were in traditional Medicare.''
Improper payments, including fraud, still bedevil Medicare and Medicaid, irking beneficiaries and politicians. The Government Accountability Office, an investigative arm of Congress, says that improper payments cost the federal government $60 billion in Medicare last year, or 10 percent of program spending, and $17.5 billion in Medicaid, or 6.7 percent.
Last month, the Justice Department, in a nationwide sweep, accused 243 people of Medicare fraud schemes involving more than $700 million in billings for services that were unnecessary or never provided. Among those charged were 46 doctors and other professionals who offered home health care, psychotherapy, physical therapy, diagnostic tests and prescription drugs.
For Medicare and Medicaid, paying for the rising cost of prescription drugs remains a daunting challenge.
''Medicare Advantage provides great coverage,'' said Nancy R. Corey, 68, a retired schoolteacher in Dayville, Conn. ''But drug costs have skyrocketed. I've spent as much on my main medications in the first six months of this year as I did in all of 2014.''
With Medicaid rolls climbing to record levels, especially in states that expanded eligibility under the Affordable Care Act, Medicaid officials also face a huge challenge finding enough doctors. In many states, doctors have been reluctant to accept Medicaid patients, in part, they say, because the fees are low.
Elizabeth A. Persaud, 36, of Alpharetta, Ga., who has a form of muscular dystrophy, receives home and community-based services through Medicaid. A personal attendant helps her get out of bed, shower, eat and go to work.
Medicaid is a boon that allows her to preserve her independence, Ms. Persaud said, but she added: ''It is difficult to find doctors in my area who accept Medicaid. I often have to have someone drive me far away to see a specialist.''
Sara Rosenbaum, a professor of health law and policy at George Washington University, said that Medicaid plans were ''once the scourge of poor communities,'' taking money without providing much care. But now, she said, they provide invaluable services to people with severe physical and mental health problems, as states often require those services in their contracts with insurers.
''The care is light-years better than what a Medicaid beneficiary would face if she had to go find an orthopedist, a rheumatologist or a podiatrist or get specialty drugs on her own,'' Ms. Rosenbaum said.
Many Medicare patients agree.
In a comment echoed by other Medicare beneficiaries, Judith M. Anderson, 69, of Chicago said: ''After a lifetime of an utterly boring personal health care history, I was diagnosed with cancer in 2013. Without Medicare, I would be bankrupt and probably dead by now. I had three surgeries and chemotherapy and paid less than $1,000 out of pocket. I love Medicare.''
URL: http://www.nytimes.com/2015/07/30/us/as-medicare-and-medicaid-turn-50-use-of-private-health-plans-surges.html
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(Taking Note)
October 1, 2012 Monday
The Most Conservative Supreme Court
BYLINE: LINCOLN CAPLAN
SECTION: OPINION
LENGTH: 495 words
HIGHLIGHT: With the new term beginning on Monday, it's worth dispelling the gauzy moderate aura that the A.C.A. decision bestowed upon the Roberts court.
After Chief Justice John Roberts Jr. sided with the four moderate liberal members of the Supreme Court to uphold the Affordable Care Act, right-wing pundits called him a traitor and left-wing pundits called him a statesman. Americans who don't generally pay attention to court decisions, but who tuned in for the health-care ruling, would therefore be excused for assuming that Chief Justice Roberts is no longer an arch-conservative but a centrist who's pulled the court to an ideological middle-ground.
But with the new term beginning on Monday, it's worth dispelling the gauzy moderate aura that the A.C.A. decision bestowed upon him and the court.
Lee Epstein and Andrew Martin, preeminent legal scholars who study the court's results from the cool perspective of political science, say the last term was little different from the previous six. The Roberts court continued as the most conservative since the anti-New Deal court of the 1930s.
John Roberts' vote in the health-care case was the sole time he joined the court's more liberal justices in any 5-4 decisions-not just in the 15 of last term, but in the 117 since he became chief justice in 2005. And his majority opinion was filled with disdainful language, what the scholar Pam Karlan in her forthcoming foreword to the Harvard Law Review's important Supreme Court issue calls "a pervasive disrespect for, and exasperation with, Congress."
That "dismissive treatment," she explains, is an expression of "lost confidence" in voters. They are also the court's constituents and they notably reciprocate the disrespect: the court's historically low standing in public opinion polls dropped even further after the health-care ruling, because, most people said, the justices on both sides had expressed political, not judicial, choices.
Professors Epstein and Martin have also brought up to date their annual analysis of the justices' ideologies-their relative conservatism or liberalism based on their voting records. The news is that Justice Samuel Alito Jr. moved even farther to the right.
It's no surprise that the upcoming presidential election could be very significant for the court. But Epstein-Martin's ideology analysis allows us to measure how different it would likely be if Mitt Romney gets to replace Ruth Bader Ginsburg compared with President Obama replacing Antonin Scalia or Anthony Kennedy. A Roberts-Alito-like replacement for Justice Ginsburg would move the court dramatically to the right. But a Kagan-Sotomayor-like replacement for Justice Scalia or Justice Kennedy would move the court to the moderate left, with the center somewhere around Justices Elena Kagan, Sonia Sotomayor, and Stephen Breyer.
As this term begins, however, the line-up's the same as last year, and there's every reason to expect the court to continue along its conservative path.
Roberts Hits the Reset Button
Five-Four
Romney's Call to Arms
Whatever Happens, I Will Have Reacted Already
The President Fumbles the Court Issue
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July 31, 2015 Friday
Late Edition - Final
Health Act Is Credited With Fueling Competition
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 582 words
WASHINGTON -- The Obama administration said on Thursday that many consumers were benefiting from increased competition among insurers under the Affordable Care Act.
Most people who bought insurance through the federal marketplace had a greater choice of health plans this year than in 2014, the administration said, and premiums rose less in counties where more insurers were competing for business.
The presence of additional insurers ''played an important role in moderating premium increases,'' said Richard G. Frank, an assistant secretary of health and human services.
The findings were based on a study of 35 states that used the online federal marketplace, HealthCare.gov, in 2014 and 2015.
The study focused on the cost of a midlevel plan, which was used as a benchmark in calculating financial assistance for consumers with low or moderate incomes. Premiums for these benchmark plans declined slightly, by 2 percent, in counties with additional insurers in 2015, but prices rose 12 percent in counties with fewer insurers, the study said.
Sylvia Mathews Burwell, the secretary of health and human services, said the study showed that ''the Affordable Care Act is working to increase choice and competition for consumers and keep premium growth in check.''
Consumers buying insurance in the marketplace are very sensitive to prices, and in many counties, they needed to switch to plans offered by a different insurance company to minimize the increase in premiums from 2014 to 2015, the report said.
Federal health officials refused to speculate on how insurance company mergers might affect premiums. Mr. Frank said the Justice Department had an extensive process to review proposed mergers.
Aetna has announced plans to acquire Humana, and Anthem has said it plans to buy Cigna. The number of big insurers would shrink to three from five if the deals go through.
With health insurance, and other products, Mr. Frank said, ''price competition typically intensifies with three or more competitors in a market.''
Benchmark premiums this year were 9 percent lower in counties with three or more insurers than in places with just one or two, the report said.
Researchers examined the choices available to people who had individual coverage or were uninsured and eligible for health plans in the federal marketplace. In 2015, the report said, 86 percent of eligible consumers had a choice of at least three insurers in the marketplace, up from 70 percent in 2014.
Mr. Frank said that competition helped keep down the growth of premiums because new insurers in a market could ''undercut prevailing premiums,'' offering prices lower than those charged by the existing insurers.
Consumers shopping in the federal marketplace generally have a greater number and variety of choices than people who have health coverage from their employers, the report said.
Fifty-nine percent of counties had an increase in the number of insurers offering health plans through the marketplace this year, and 8 percent had a decrease. In the remaining counties, the number of insurers did not change.
Researchers found more competition in more populous counties, and they said that markets with higher enrollment in 2014 were more likely to attract additional insurers in 2015.
The scrutiny of county-level data was important, officials said, because premiums for a plan can vary greatly in a state. California, for example, has 19 geographic rating areas, or pricing regions, and Michigan has 16.
URL: http://www.nytimes.com/2015/07/31/us/increased-competition-kept-lid-on-health-insurance-inflation-us-says.html
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June 18, 2015 Thursday
Late Edition - Final
Destructive Health Care Proposals
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 30
LENGTH: 503 words
Frustrated by their inability to repeal the Affordable Care Act and unable to produce a conservative alternative to replace it, House Republicans are moving two bills to repeal small but important provisions of the law -- a tax on medical device manufacturers and an independent board to clamp down on out-of-control Medicare spending. The two bills would harm the federal budget and do nothing to help consumers, but were approved by the House Ways and Means Committee and are expected to pass the House on Thursday.
The Affordable Care Act imposes a modest 2.3 percent tax on revenues from sale of medical devices in this country, to be paid by the manufacturers or importers. The tax applies to big-ticket devices like M.R.I. scanners, X-ray machines, artificial joints and pacemakers, but not to consumer items like eyeglasses, contact lenses or hearing aids. Repealing the tax would reduce revenues, and thus increase federal deficits, by an estimated $24.4 billion over the next 10 years. The bill provides no way to replace the lost revenue.
Industry spokesmen claim the tax, which took effect in 2013, is thwarting innovation by absorbing funds that could pay for research. And they say it will drive some companies to move production facilities abroad. But independent analysts have shown such claims to be wildly exaggerated. The device industry appears to be thriving from increased business generated by the reform law and, like other industries benefiting from the law (insurers and drug makers), it ought to pay to help support it.
With almost two-thirds of the House co-sponsoring the bill to repeal the tax, it is virtually certain to pass and be sent to the Senate, where four-fifths of the members expressed support for repealing the tax in 2013. President Obama ought to veto this handout to an industry that deserves no special privileges.
The bill to repeal the Independent Payment Advisory Board, co-sponsored by more than half of the House's members, is also expected to pass. The board, to be composed of nongovernmental experts, is meant to act as a brake on excessive spending in the Medicare program. If per capita spending in Medicare exceeds specified targets, the board, whose members have not yet been appointed by the president, must recommend changes (most likely cuts in payments to health care providers) that will become law unless Congress finds alternative, equal savings.
The board has been vilified by conservative critics with outlandish charges that it will ration care, tell patients what treatments they can receive and disrupt doctor-patient relationships. In reality, the board is prohibited by law from making any recommendations to ration care, restrict benefits, limit eligibility, or increase premiums or cost-sharing. Its primary role is to stiffen Congress's spine by insulating it from powerful health care lobbies and forcing it to act when Medicare spending runs off the rails. If a bill to get rid of the board reaches his desk, Mr. Obama should veto it as well.
URL: http://www.nytimes.com/2015/06/18/opinion/destructive-health-care-proposals.html
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March 10, 2017 Friday
Late Edition - Final
Trump Jumps In, Trying to Propel Health Care Bill
BYLINE: By MAGGIE HABERMAN and ROBERT PEAR; Jeremy W. Peters contributed reporting from Washington, and Kate Kelly from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1561 words
WASHINGTON -- President Trump, after a halting start, is now marshaling the full power of his office to win over holdout conservatives and waffling senators to support the House Republicans' replacement for the Affordable Care Act.
There are East Room meetings, evening dinners and sumptuous lunches -- even a White House bowling soiree. Mr. Trump is deploying the salesman tactics he sharpened over several decades in New York real estate. His pitch: He is fully behind the bill to scotch President Barack Obama's signature domestic achievement, but he is open to negotiations on the details.
In so doing, Mr. Trump is plunging personally into his first major legislative fight, getting behind a bill that has been denounced by many health care providers and scorned by his base on the right. If it fails, Mr. Trump will find it difficult not to shoulder some of the blame.
''He understands the power he has as president to drive the legislative process,'' said Representative Patrick T. McHenry, Republican of North Carolina and a top House vote counter, who was part of a meeting with Mr. Trump in the East Room on Tuesday.
''He made it clear that this is his priority, that it has to get done, and he made clear that he has to get it through before he moves on tax reform,'' Mr. McHenry added.
The bill represents an opening for an administration that has been mired in infighting and controversy over an early executive action on immigration. And it will allow Mr. Trump to make good on a pledge he made in rally after rally in 2016 to replace Mr. Obama's law, which he called a ''disaster.''
And it has momentum. On Thursday, two key House committees approved the legislation, which would undo the Affordable Care Act and replace it with a more modest system of tax credits and a rollback of Mr. Obama's Medicaid expansion. Party-line votes by the House Energy and Commerce and Ways and Means Committees sent the measure to the House Budget Committee for consideration next week before a final House vote that Speaker Paul D. Ryan plans for later this month.
''Today marks the beginning of the end of Obamacare,'' Representative Steve Scalise of Louisiana, the majority whip, declared after the votes.
The risks for Mr. Trump are high. His initial foray into the debate was a declaration that nobody should lose insurance coverage with a replacement bill -- a standard that is likely to be impossible to meet. When House Republicans finally unveiled the legislation Monday night, he declared on Twitter, ''Our wonderful new Healthcare Bill is now out for review and negotiation'' -- hardly a hard line.
Already, debate on the measure is taking far longer than Mr. Trump had hoped, delaying his push to cut taxes, rewrite the tax code and secure a sizable new infrastructure program. If his health care push fails, the reverberations will affect those other measures.
For all of Mr. Trump's characteristic bluster, the self-described king of the deal is treading gingerly on the actual policies in the bill. Since members of the hard-line House Freedom Caucus complained that they were not being listened to by the House Republican leadership, Mr. Trump has sought to bring them along by listening to their concerns before dictating his desires, his advisers say.
For now, those advisers say, Mr. Trump is in listening mode. He had dinner on Wednesday with Senator Ted Cruz of Texas, who is leery of the House bill. He got an earful from conservative opponents of the bill when he met at the White House with representatives of the Heritage Foundation and Americans for Prosperity on Wednesday night.
On Thursday afternoon, the White House director of social media, Dan Scavino Jr., posted a photo on Twitter of the president sitting around a table at a meeting that Mr. Scavino said was budget-related. But among those at the table with the president were Representative Mark Meadows of North Carolina, the chairman of the Freedom Caucus, and Representative Jim Jordan of Ohio, two of the biggest obstacles to any health care bill deemed insufficiently thorough in obliterating the Affordable Care Act.
The president has not spent enormous time negotiating specific aspects of the bill, people who have spoken with him say. But some of his advisers have been critical of the House Republican Conference, led by Mr. Ryan, for not doing more to bring along conservative members. The meeting at the White House with leaders of conservative groups was an effort to remedy that, Mr. Trump's aides said.
And in a sign of the White House still grappling with how tightly it wants to embrace the current bill, Vice President Mike Pence will appear instead of Mr. Trump on a trip to Louisville, Ky., this weekend. On Wednesday, Mr. Trump will hold a campaign rally in Nashville, where he is also expected to barnstorm for the repeal of the Affordable Care Act.
''The president will be visiting several cities over the next coming weeks to engage the American people on the need to repeal and replace,'' Sean Spicer, the White House press secretary, said on Thursday.
Last week, Mr. Trump's aides grew frustrated when the House Republican leadership bluntly told them that the president would need to use his political capital to bring people along. The tensions fall squarely in the purview of Reince Priebus, Mr. Trump's chief of staff, who is close to Mr. Ryan and who some of the president's advisers fear has divided loyalties. Mr. Trump vented his frustrations with Mr. Priebus last Friday over how much work remained toward preparing for the health bill rollout.
Mr. Trump's advisers mostly welcomed the discussion of the bill as a reprieve from the controversy over Mr. Trump's post on Twitter saying, without evidence, that he had information that Mr. Obama had ''tapped'' Mr. Trump's phones at Trump Tower during the campaign.
Those advisers are also aware that the rollout of the plan has been bumpy, with only deeply limited spade work done by the House Republican Conference to shore up outside support beforehand. Nudged by frustrations from the West Wing, Mr. Ryan on Thursday conducted a PowerPoint presentation with members of the news media to explain the three phases planned for repealing and replacing the A.C.A.
But White House advisers are well aware that they are saddled with the bill now. At the same time, they describe Mr. Trump as walking lightly -- by his standards, at least.
The vice president's trip to Kentucky will bring Mr. Pence to a state that is being treated as ground zero in the repeal fight. Kentucky's junior senator, Rand Paul, is the bill's most prominent Republican critic. Its former governor, Steve Beshear, became a Democratic hero for successfully implementing the health care law in the deep red state, but Republicans took full control of its statehouse in elections last year despite the Democrats' strong support for the Affordable Care Act.
There is some daylight between the House Republican leaders and the White House on how much change the bill can absorb. Representative Joe L. Barton, Republican of Texas, offered an amendment on Thursday that would have moved the health care bill in a conservative direction, reducing federal funds for the Affordable Care Act's expansion of Medicaid at the end of 2017, two years earlier than under the legislation drafted by House Republican leaders.
Mr. Barton withdrew the amendment but hinted that it could reappear when the bill hits the House floor. The proposal was supported by two influential conservative groups, the Republican Study Committee and the House Freedom Caucus -- and, he said, ''the Trump administration is open to it.'' Indeed, the White House has begun pushing for a 2017 end to the Medicaid expansion, a senior Trump adviser confirmed -- a move that risks pushing away moderates across Congress.
Mr. Trump also wants the Republicans' health care bill to inject more consumer choice into the process of selecting plans, said someone familiar with the president's thinking, as well as the elimination of state-by-state insurance options. Such changes are impossible under the budget rules that Republicans are using to avoid a Democratic filibuster in the Senate.
Representative McHenry said Mr. Trump talked in the meeting this week about how he had performed in the districts of lawmakers whose votes will be necessary.
The criticism of the bill from conservative groups grew so hostile so quickly that it surprised even Mr. Trump. So Mr. Trump moved to use the trappings of the presidency to woo them.
Initially, the group was told it would see the president in the Roosevelt Room. But after the group's members waited there for a short while, an aide entered and said, ''The president would like to see you in the Oval Office.''
Even so, it quickly became evident that the objections the activists had with the bill could not be washed away with the awe of the Oval Office. The president told them he did not appreciate the attacks on the proposal as ''Obamacare lite'' or something that fell short of a repeal. That kind of talk, he warned them, could be detrimental to their shared cause of gutting the Affordable Care Act.
Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.
This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2017/03/09/us/politics/health-bill-clears-house-panel-in-pre-dawn-hours.html
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GRAPHIC: PHOTOS: At left, President Trump with Representative Steve Scalise of Louisiana in the East Room on Tuesday, part of efforts to propel the health bill. At right, Representative Brett Guthrie of Kentucky as a House panel considered the bill before approving it Thursday. (PHOTOGRAPHS BY DOUG MILLS/THE NEW YORK TIMES
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October 1, 2013 Tuesday
Late Edition - Final
Obama Confident, but Wary of Economic Fallout
BYLINE: By JACKIE CALMES
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 934 words
WASHINGTON -- President Obama expressed confidence on Monday that he was right to defy House Republicans' demands as the hours ticked away toward a government shutdown. Yet offsetting the bravado at the White House was fear of what October's unfolding events could mean for the economy.
A day before uninsured Americans could begin signing up for coverage under the Affordable Care Act, the law that is the white-hot center of the political conflagration, Mr. Obama appeared self-assured but was nonetheless powerless to influence scores of uncompromising Republicans -- many of them elected since he took office -- who have bucked both their own party leaders and traditionally influential business groups. As he acknowledged, five years of work to prevent a second Depression and then spur a slow recovery was at risk of being undone, depending on how the month plays out.
Hope for a short-term deal to fund the domestic and military operations of government slipped away as a new fiscal year began Tuesday at 12:01 a.m., and a fight is inevitable as the president and Congressional Republicans seek agreement for a full-year budget. The biggest, most economically threatening showdown still threatens: By Oct. 17, Congress must raise the nation's debt limit to pay for bills already incurred or provoke a globe-shaking default.
So this is not a fight that Mr. Obama is relishing. Nor is it the one he expected when he ran for a second term, wrongly predicting last year that his re-election would break Republicans' ''fever'' of opposition to him and his agenda, including the nearly four-year-old health care law.
Instead, House Republicans insist on defunding or at least delaying the 2010 health care law, just as its central provision is to take effect on Tuesday. They are convincingly vowing to oppose either a federal budget or an essential increase in the debt ceiling unless Mr. Obama agrees. The president just as persuasively refuses.
''Here's the bottom line,'' Mr. Obama told reporters in the White House briefing room in the late afternoon. ''I'm always willing to work with anyone of either party to make sure the Affordable Care Act works better, to make sure our government works better.''
Mr. Obama said that ''time and time again'' he had shown his willingness to compromise, ''oftentimes to the consternation of my own party.''
''But one faction of one party, in one house of Congress, in one branch of government doesn't get to shut down the entire government just to refight the results of an election,'' Mr. Obama said. ''Keeping the people's government open is not a concession to me.''
Afterward, the president met with his cabinet to coordinate what a shutdown of government operations would entail and to ensure that ''core essential functions continue.''
Even as the Affordable Care Act was at the center of the divisive budget debate, the White House juggled the last-minute practical and communications work of putting a core piece of the law into effect on Tuesday. That was the long-anticipated start of open enrollment for the health-insurance marketplaces, known as exchanges, that are intended to eventually make competitively priced coverage available to the estimated 15 percent Americans who are uninsured.
While the White House waited for the Republican-controlled House and the Democratic-led Senate to go through the final legislative motions to make their budget impasse official, Mr. Obama was preoccupied with an event that on a normal day would be big news on its own -- a White House visit from Prime Minister Benjamin Netanyahu of Israel. The meeting came just days after Mr. Obama broke a 34-year freeze in top-level contacts between the United States and Iran, Israel's nemesis, with a phone conversation with Iran's president, Hassan Rouhani.
On Capitol Hill, Republicans made much of Mr. Obama's willingness to talk to the Iranians, but not to them, and called him ''AWOL'' on the budget. But neither Mr. Obama nor his advisers showed concern that many Americans would agree with the Republicans and blame Mr. Obama for refusing to negotiate about demands that would undercut the 2010 health insurance law, his signature domestic achievement.
So there were no negotiations, and the administration began preparations to shut down government, and to place blame on Republicans.
In the evening, Mr. Obama separately called the Republican and Democratic leaders of both the House and the Senate, but there were no indications of any ice-breaking. According to a White House statement, the president thanked the Democrats, Senator Harry Reid and Representative Nancy Pelosi, for supporting the ''clean'' Senate-passed measure to finance the government for six weeks at current levels, and he urged Speaker John A. Boehner to have the House pass it as well before midnight.
Early in the day, as Mr. Obama sat alongside Mr. Netanyahu for a brief appearance before reporters and photographers, he alluded to the potential global ramifications of a shutdown and default.
''There's not a world leader, if you took a poll, who would say that it would be responsible or consistent with America's leadership in the world for us not to pay our bills,'' the president said. ''We are the foundation of the world economy and the world financial system.''
All day, against all evidence to the contrary, he expressed confidence ''that in the 11th hour, once again, that Congress will choose to do the right thing and that the House of Representatives in particular will choose the right thing.''
But however the issue was resolved, it would most likely only buy time until the next crisis.
URL: http://www.nytimes.com/2013/10/01/us/politics/as-congress-spars-over-budget-obama-sidelines.html
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GRAPHIC: PHOTOS: President Obama and his cabinet on Monday discussed a shutdown, including the continuation of ''core essential functions.''
Lights burned in the West Wing late Monday night as Mr. Obama and his staff monitored developments on Capitol Hill. (PHOTOGRAPHS BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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August 24, 2012 Friday
Evidence vs. Ideology in the Medicare Debate
BYLINE: LAURA D'ANDREA TYSON
SECTION: BUSINESS; economy
LENGTH: 1352 words
HIGHLIGHT: If Republican leaders were serious about strengthening Medicare, they would find a way to lower costs, rather than passing on the risk of higher premiums to the elderly, an economist writes.
When formulating public policy, evidence should be accorded more weight than ideology, and facts should matter more than shibboleths. The Romney-Ryan plan for Medicare reform depends on assertions that are ideologically consistent. But the Republicans plan is not supported by the evidence and does not survive serious scrutiny.
Perhaps that's why the Romney campaign has been deliberately misrepresenting President Obama's Medicare record.
Mitt Romney characterizes the $716 billion of Medicare savings over the next 10 years, contained in the Affordable Care Act, as President Obama's "raid" on the Medicare program to pay for his health care program. This fear-mongering is simply untrue. These savings result from reforms to slow the growth of Medicare spending per enrollee - there are no cuts in Medicare benefits.
The reforms include both voluntary and mandatory changes in how providers deliver health care to promote better care coordination at lower cost, reward the quality and outcomes of services rather than their volume and reduce fraud and abuse.
For example, the law fosters the creation of accountable-care organizations, i.e., groups of providers willing to accept a flat fee for the integrated care provided to their Medicare patients. Accountable-care organizations represent a major step away from the unsustainable fee-for-service model that rewards the number of procedures rather than the quality of care.
Health experts believe that these organizations will significantly improve care and lower costs not just in Medicare but throughout the health care system. This belief is based on evidence, not ideology.
Medicare beneficiaries will also benefit from reforms that penalize hospitals for preventable re-admissions reflecting complications from previous procedures and that require hospitals to post their rates of medical errors, with penalties for those with the highest rates.
Both Governor Romney and Representative Paul D. Ryan have promised to repeal the Affordable Care Act and with it the reforms behind the $716 billion in Medicare savings (although Mr. Ryan duplicitously counts the savings from these reforms in his deficit-reduction plan). Medicare beneficiaries would be the losers. They would lose the benefits of better care at lower cost. They would lose the plan's expanded Medicare coverage for prevention benefits and prescription drugs, and they would be forced to pay higher premiums and co-pays as a result of faster growth in Medicare costs.
President Obama's health care plan is not a raid on Medicare; it is . If the Affordable Care Act had not met this standard, the AARP would not have endorsed it.
The plan adds eight years to the solvency of the Medicare Trust Fund while reducing the federal deficit by more than $100 billion over the next 10 years and by about a half of 1 percent of gross domestic product, or about $1 trillion from 2023 through 2032. This is according to the Congressional Budget Office, a trusted nonpartisan arbiter in federal budgetary matters.
In contrast, the last major health legislation, the 2003 Medicare prescription drug bill, added about $400 billion to the 10-year deficit. Mr. Ryan, the self-described deficit firebrand, supported this bill, without a single dollar in savings or additional revenue to offset its costs.
Now Mr. Ryan has espoused - and Governor Romney has embraced -- a proposal to transform Medicare into a premium support system. This is part of the Romney-Ryan plan to reduce the federal deficit while cutting taxes, especially for high-income earners, and slashing spending on Medicare and other government programs.
Among commentators, fiscal responsibility is often equated with imposing some of the burden of deficit reduction on Medicare beneficiaries. This is a meretricious gauge of fiscal "seriousness."
Representative Ryan has won praise from many deficit hawks for his advocacy of premium support, but this praise is unwarranted. There is no evidence that such a system would control Medicare spending more effectively than the current Medicare program strengthened by Affordable Care Act reforms. Indeed, the evidence points decisively in the opposite direction.
In Mr. Ryan's latest premium-support proposal, the government would provide a subsidy to Medicare beneficiaries to choose among competing insurance plans, including the traditional fee-for-service Medicare plan. Starting for 65-year-olds in 2022, insurance plans would take part in an annual bidding process to compete for Medicare beneficiaries. The bids would reflect the actual growth of health-care costs and would determine the size of the federal subsidy.
Advocates of premium support argue that competition would encourage more cost-sensitive behavior by beneficiaries, providers and insurers. The facts do not support this.
Just consider that despite competition and choice, private insurance premiums per enrollee for comparable coverage have increased more rapidly than Medicare spending per enrollee for more than 30 years. Medicare's superior performance is all the more remarkable since its elderly beneficiaries include a sizable share of the sickest individuals who are the largest consumers of health care services. And Medicare's cost advantage is likely to continue into the future.
According to a recent study, with implementation of the Affordable Care Act reforms, Medicare spending per enrollee is likely to grow by 3.1 percent a year during the next 10 years, about the same as the projected annual growth rate for G.D.P. per capita, while private insurance per enrollee is likely to grow by 5 percent a year.
What explains Medicare's sustained cost advantage over private insurance? Medicare has much lower administrative costs than private insurance. And Medicare has considerable negotiating leverage with providers as a result of its huge enrollment. The new law strengthens this leverage. Private insurance plans have been unwilling or unable to drive reforms to reduce provider costs, preferring instead to pass rising costs on to consumers through higher premiums, relying on Medicare to spearhead efficiency-enhancing reforms.
As I explained in a previous Economix post, this is why the C.B.O. has consistently refused to recognize large potential savings in health care costs from reforms that merely increase competition among private insurance plans.
Indeed, the C.B.O. has concluded that replacing traditional Medicare with competition among such plans would drive up total health-care spending per Medicare beneficiary. Which is why Representative Ryan was compelled to place an arbitrary growth cap on the size of the subsidy in his premium support proposal.
That was the only way he could secure C.B.O.-scored budgetary savings. But imposing such a cap separates the growth of the subsidy from the growth of health care costs and transforms the premium-support system into a voucher system.
A voucher system would do little to control the growth of health care costs, but it would shift their burden onto Medicare beneficiaries in the form of higher premiums and reduced care. Cost-shifting should not be confused with cost containment.
Mr. Ryan asserts that the 1998 bipartisan Medicare Commission proposed premium support as a solution to Medicare's financing challenges. But he fails to mention that all of the commission members appointed by President Clinton, including me, voted against this idea.
Since then, the evidence has confirmed that competition among private insurance plans would not yield Medicare savings without harming beneficiaries. To achieve this goal, enforceable payment and cost-containment reforms like those in the Affordable Care Act are necessary.
A "serious" deficit hawk committed to saving and strengthening Medicare, not one whose primary goals are repealing health-care reform and cutting taxes for the wealthy, would base his Medicare plan on the evidence. Mr. Ryan and his running mate can't be serious.
Medicaid Expansion and Jobs
Define 'Welfare State,' Please
Mitt Romney and Paul Ryan's Budget
Determining the Level of Payments in Health Care
Wyden-Ryan's Unrealistic Assumptions
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November 29, 2016 Tuesday
Late Edition - Final
Fierce Critic of Health Care Law Said to Be Pick for Health Dept.
BYLINE: By ROBERT PEAR; Maggie Haberman contributed reporting from New York.
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1107 words
WASHINGTON -- If President-elect Donald J. Trump wanted a cabinet secretary who could help him dismantle and replace President Obama's health care law, he could not have found anyone more prepared than Representative Tom Price, who has been studying how to accomplish that goal for more than six years.
Mr. Price, an orthopedic surgeon who represents many of the northern suburbs of Atlanta, speaks with the self-assurance of a doctor about to perform another joint-replacement procedure. He knows the task and will proceed with brisk efficiency.
Mr. Trump has picked Mr. Price, a six-term Republican congressman, to be secretary of health and human services, according to a transition team official.
Also on Monday, Mr. Trump met with David H. Petraeus, the highly decorated but scandal-scarred former military commander, who has emerged as a new contender for secretary of state.
While some Republicans have attacked the Affordable Care Act without proposing an alternative, Mr. Price has introduced bills offering a detailed, comprehensive replacement plan in every Congress since 2009, when Democrats started work on the legislation. Many of his ideas are included in the ''Better Way'' agenda issued several months ago by House Republicans.
In debate on the Affordable Care Act in 2009, Mr. Price railed against ''a stifling and oppressive federal government,'' a theme that pervades his politics. His most frequent objection to the law is that it interferes with the ability of patients and doctors to make medical decisions -- a concern he will surely take with him if he wins Senate confirmation.
''The practicing physician and the patient could not have a better friend in that office than Tom Price,'' said Representative Michael C. Burgess, Republican of Texas, who is also a physician.
Mr. Price, the chairman of the House Budget Committee, said he felt events had borne out his warnings about the health law.
''Congressional Democrats and the Obama administration blatantly ignored the voices of the American people and rammed through a hyperpartisan piece of legislation that will have a disastrous effect on our nation's health care system,'' Mr. Price said shortly after Mr. Obama signed the bill in 2010.
Now, he says: ''Premiums have gone up, not down. Many Americans lost the health coverage they were told time and time again by the president that they could keep. Choices are fewer.''
The legislation Mr. Price has proposed, the Empowering Patients First Act, would repeal the Affordable Care Act and offer age-adjusted tax credits for the purchase of individual and family health insurance policies.
The bill would create incentives for people to contribute to health savings accounts; offer grants to states to subsidize insurance for ''high-risk populations''; allow insurers licensed in one state to sell policies to residents of others; and authorize business and professional groups to provide coverage to members through ''association health plans.''
As secretary, Mr. Price would be responsible for a department with an annual budget of more than $1 trillion, health programs that insure more than 100 million Americans, and agencies that regulate food and drugs and sponsor much of the nation's biomedical research.
From his days as a Georgia state senator, Mr. Price, now 62, has been a voice for doctors, often aligned with the positions of the American Medical Association and the Medical Association of Georgia.
He has introduced legislation that would make it easier for doctors to defend themselves against medical malpractice lawsuits and to enter into private contracts with Medicare beneficiaries. Under such contracts, doctors can, in effect, opt out of Medicare and charge more than the amounts normally allowed by the program's rules.
Mr. Price's intimate knowledge of Medicare could serve him well. The secretary of health and human services sets Medicare payment policies for doctors, updates the physician fee schedule each year and issues rules that can have a huge influence on the practice of medicine. The government is carrying out a law that changes how doctors are paid under Medicare, and Medicare often serves as a model for private insurers.
On the other hand, as secretary, Mr. Price would need a broader perspective. He would have to consider not only the interests of doctors, but also the needs of Medicare beneficiaries, Medicaid patients and taxpayers who finance those programs.
Mr. Price is a strong conservative who invariably excites the audience at the annual Conservative Political Action Conference. His website lists him as a member of the Tea Party Caucus. His district includes territory once represented by Newt Gingrich, a former speaker of the House. But Mr. Price is no bomb thrower. He works within the system and has led two groups that promote conservative policies in the House.
Born in Lansing, Mich., Mr. Price went to college and medical school at the University of Michigan, did his residency at Emory University in Atlanta and was medical director of the orthopedic clinic at Grady Memorial Hospital in Atlanta.
He says he got into politics because he found that officials in Washington and Atlanta who had no medical training were making decisions that affected his ability to take care of patients.
Speaking at a political conference in early 2010, Mr. Price said he was proud to join fellow conservatives in an effort to beat back a ''vile liberal agenda.''
In a similar vein, he complained this year that Obama administration officials were trying to ''commandeer clinical decision-making'' by forcing doctors to participate in experiments that test new ways of paying for prescription drugs, hip and knee replacement operations, and heart surgery for Medicare patients.
As secretary of health and human services, Mr. Price could carry out the advice he has given Mr. Obama: ''Stop these mandatory demonstration projects.''
Mr. Price is also an outspoken opponent of abortion and has consistently received ratings of 100 percent from the National Right to Life Committee and scores of zero from the Planned Parenthood Federation of America.
Gay rights groups have also been critical of Mr. Price. Sarah Kate Ellis, the president and chief executive of GLAAD, formerly known as the Gay and Lesbian Alliance Against Defamation, said Mr. Price was ''completely unfit'' to be health secretary.
When the Supreme Court ruled last year that the Constitution guarantees a right to same-sex marriage, Mr. Price said it was ''not only a sad day for marriage, but a further judicial destruction of our entire system of checks and balances.''
URL: http://www.nytimes.com/2016/11/28/us/politics/tom-price-secretary-health-and-human-services.html
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Tom Price, at Trump Tower Nov. 16, has offered a detailed alternative to the Affordable Care Act. (PHOTOGRAPH BY HILARY SWIFT FOR THE NEW YORK TIMES) (A17)
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(Economix)
January 17, 2014 Friday
The Real Health Care 'War' on the Young
SECTION: BUSINESS; economy
LENGTH: 1256 words
HIGHLIGHT: Those who criticize Obamacare as discriminatory against young men have turned a blind eye to how health insurance premiums are traditionally established, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
A common theme among critics of Obamacare has been that it basically is a war on the young and especially on men.
"Why aren't Millennials marching in the street over Obamacare?" asks Chris Conover, a policy analyst at Duke University, in Forbes. "Anyone with a conscience should be offended by the greatest generational theft ever witnessed in the history of the world. Young Americans - especially the Millennial generation born between 1977 and 1995 - are the biggest losers in this battle, but it will adversely affect their children and grandchildren to boot."
The most seriously victimized by Obamacare, its critics say, are men. Possibly inspired by John Goodman's column "Obama's War on Men" on the National Center for Policy Analysis health care blog, Avik Roy, a Forbes columnist and Manhattan Institute senior fellow, metaphorically described Obamacare in a Fox News interview as a "war on the bros."
The destructive weapon supposedly wreaking this havoc on the young and the "bros" is the "adjusted community rating" that the Affordable Care Act imposes on the market for health insurance policies sold to individuals or small groups (mainly the employees of small businesses). Although the act allows insurers to vary their premiums by age up to a ratio of 3 to 1 and to charge smokers 50 percent more than nonsmokers within an age group - hence the term "adjusted" community rating - premiums may no longer be based on the health status of individuals within age bands nor on their gender.
Now, one certainly can have misgivings over community rating on actuarial grounds. From the perspective of commercial health insurance, it is an unnatural act. As I noted in an earlier post, community rating invites adverse risk selection by individuals against the insurers' risk pools, which, in turn, may lead to the so-called death spiral in health insurance, unless the risk pools can attract enough relatively healthier individuals. Therein lies the case for compelling individuals of all ages to purchase health insurance.
But the authors cited above do not base their case on purely technical, economic grounds. Language such as "the greatest generational theft in world history" or "a war on the bros" is meant to generate moral outrage.
A case in point is the gender neutrality baked into the community rating required by Obamacare, which has unleashed this so-called war.
Before the Affordable Care Act, premiums for women in the younger age groups in the individual and small-group market were as much as 70 percent higher than those of men of similar age because women bear children, which brings with it greater use of health care and thus higher actuarial costs. Imposing gender-neutral community rating on such a market inevitably leads to some economic transfer from men to women through the channel of the community-rated premium, relative to pre-Obamacare premiums.
Among many Americans and most Europeans and Asians - men included - this mandated gender neutrality is noncontroversial. Perhaps it is thought of as a small token of gratitude for the extraordinary contribution to humanity women make in this regard.
Besides, there is growing scientific evidence that the physical and intellectual development of humans into adulthood is strongly influenced by their experience and nutrition in utero and during early childhood. Thus, a nation does not even have to be particularly humane, but merely smart, to grant women of child-bearing age easy access to the best maternal and child care attainable, including good nutrition. It is a solid economic investment with high social returns over generations.
Yet as I have noted previously, many other Americans seem to view children more in the nature of lovable human pets - that is, more in the nature of a private good than a precious social resource. Furthermore, some people may still be unfamiliar with the emerging literature on fetal origins and early childhood development. At any rate, there evidently is a vocal school of thought in this country that views equalizing health insurance premiums for men and women through community rating as unjust - as a "war on the bros."
Whatever one's view on the moral case for or against gender-neutral community rating, no one disputes that, relative to the situation in the individual and small-group health insurance market before the Affordable Care Act, that act does lead to the economic transfers denounced by the law's critics, although the provision of age bands curbs the transfers considerably.
So it is natural to inquire how the private sector outside the individual and small-group market has handled this potential economic conflict between the young and the old, men and women and the healthy and sick. Is Obamacare unique in unleashing war upon the young, on the healthy and on the "bros" in the United States? The answer is no.
Every employed American must realize that employment-based health insurance coverage is implicitly community rated with respect to age, gender and health status.
Two individuals performing roughly the same job and acquiring the same health insurance policy - one young and healthy, the other older and stricken, perhaps, with diabetes or a recent bout of cancer - will not be asked to make different contributions to their health insurance coverage. Nor would their take-home pay reflect their age and health status through a backward shifting of the employers' premium contribution.
Older members of Congress and their older staff members have for decades graciously accepted the cross-subsidies younger colleagues have made toward these elders' health insurance through the fully community-rated premiums quoted them under the Federal Employees Health Benefits Program. It is only now, forced by the Affordable Care Act to purchase their coverage on their states' health insurance exchanges, that they get a taste of age-rated premiums.
Finally, it strikes me as a safe bet that those most vociferously decrying the "greatest generational theft ever witnessed in the history of the world" and "the war on the bros" imputed to Obamacare also enjoy health insurance coverage based on implicit, non-age-adjusted community rating.
We may conclude, therefore, that if Obamacare can be accused of having unleashed war upon the young and especially on the "bros," then private employers, who typically do not even use age bands or gender differentiation in their health insurance programs, can be said metaphorically to have nuked these hapless ones.
Think about it! In dollar magnitude, the generational theft that employers in the United States have visited on the young, on the healthy and on the "bros" among their employees is even greater than "the greatest generational theft in world history." Being greater than the greatest - even as a thief - is no mean feat.
And where were the champions of the young and of vulnerable men while that much larger generational theft and that much longer "war on the bros" in employment-based coverage has raged for more than half a century?
As the economist Austin Frakt pointedly asked on his blog a while ago, "Where is the outrage over employer-sponsored coverage in the 'rate shock' debate?"
Medicare Advantage and the 'Theft' of $156 Billion
Shorter Workweeks Are Likely in New Year
The Economics of Being Kinder and Gentler in Health Care
Health Care Prices Move to Center Stage
Conflicting Pressures on Demand for Doctors
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April 19, 2016 Tuesday
Late Edition - Final
Republican Health Care Myths
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 26
LENGTH: 716 words
''Disaster.'' ''Incredible economic burden.'' ''The biggest job-killer in this country.''
Central to the presidential campaigns of Donald Trump and Ted Cruz has been the claim that the Affordable Care Act has been a complete failure, and that the only way to save the country from this scourge is to replace it with something they design.
It's worth examining the big myths they are peddling about the Affordable Care Act and also their ill-conceived plans of what might replace it.
Millions of people have lost their insurance: In January, Mr. Cruz claimed that ''millions of Americans'' had lost their health insurance because of the health reform law. He even claimed to be one of them, saying ''our health care got canceled'' because Blue Cross Blue Shield left the individual market in Texas.
Insurers did stop offering some plans after the law took effect, including those that didn't provide required benefits like maternity care or that charged higher premiums to older or sicker people. But people with those plans had the opportunity to sign up for others. And over all, the law has drastically reduced the number of Americans who lack health insurance. According to the Census Bureau, the number of uninsured Americans dropped by 10 million between 2010, when the law passed, and 2014. While critics said employers might stop offering health insurance because of the law, three million people actually gained coverage through their employers between 2010 and 2014.
Incidentally, Mr. Cruz never lost his health insurance. Blue Cross Blue Shield did cancel his particular plan, but it automatically moved him and his family to a new one. A Cruz spokeswoman said the senator had been misinformed by his insurance broker.
Millions of people have lost their jobs: Mr. Cruz has called the Affordable Care Act ''the biggest job-killer in this country'' and said ''millions of Americans have lost their jobs, have been forced into part-time work'' because of it. This is false. The unemployment rate has fallen since the law took effect, PolitiFact notes, as has the number of people working part time when they would rather work full time. A 2015 study using data from the Current Population Survey found that the law ''had virtually no adverse effect on labor force participation, employment or usual hours worked per week through 2014.''
Reduce costs by weakening state regulations: Mr. Trump frequently talks about his plan to ''get rid of the lines around the states'' to foster competition among insurance companies. Customers in states where insurance is heavily regulated, the thinking goes, would be able to save money if they could purchase coverage from insurers based in states with fewer rules. Mr. Cruz, too, supports allowing people to buy insurance across state borders -- it's one of the few proposals he's offered for replacing the health law if it is repealed.
But the biggest obstacle stopping insurers from setting up in more states is not regulation; it's the difficulty of establishing a network of providers in a new market. And such a structure would destroy the longstanding ability of states to regulate health insurance for their populations. Some states, for instance, require coverage for infertility treatment and others have chosen not to. Allowing cross-border plans would encourage insurers to base themselves in low-regulation states, and the result might be a proliferation of poor-quality plans.
The Affordable Care Act is not perfect. Premiums for plans on the exchanges rose between 2015 and 2016 and are likely to rise again next year. A few insurers have left the exchange market, raising concerns in some quarters that more companies might follow.
But the law has helped millions of Americans, especially low-wage workers like cashiers, cooks and waiters who previously struggled to pay for coverage. In inventing problems that don't exist and proposing solutions that won't help, Donald Trump and Ted Cruz show that they don't care about helping Americans get health care, which has never been their interest. They want to trash the Affordable Care Act, and they're willing to mislead the public any way they can.
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URL: http://www.nytimes.com/2016/04/19/opinion/debunking-republican-health-care-myths.html
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November 24, 2013 Sunday
Late Edition - Final
In the Health Law, an Open Door for Entrepreneurs
BYLINE: By CLAIRE MARTIN
SECTION: Section BU; Column 0; Money and Business/Financial Desk; PROTOTYPE; Pg. 3
LENGTH: 1632 words
In the weeks since the health insurance marketplaces of the Affordable Care Act went online, a well-publicized ripple of alarm and confusion has permeated the ranks of small-business owners. But less well known is the response of another contingent: newcomers to entrepreneurship who see the legislation as a solution to the often insurmountable expense of getting health insurance. Some even view the Affordable Care Act itself as a business opportunity.
The hopeful include founders of start-ups who otherwise wouldn't have access to affordable health insurance -- people like Rajeev Jeyakumar, a co-founder of Skillbridge, a Manhattan-based online job marketplace for business consultants.
Mr. Jeyakumar is uninsured. But unlike many people who were thwarted by the government's faulty health care website, he was able to sign up for individual coverage three weeks ago. He will pay just $74 a month, after tax credits, for his new plan through the New York State exchange.
His story illustrates how, when finances are tight, new entrepreneurs often place the health of their businesses over their own health. ''In the early days, a venture is often very much self-funded,'' Mr. Jeyakumar says. ''You always trade off between the money you need to survive in terms of paying rent and food. And when you have health care as an additional cost, it's always very tempting to not put money into it.''
But come January, Mr. Jeyakumar will have a health plan that ''even includes dental,'' he wrote in an email. ''I'm very pleased with the outcome.'' Until then, he's refraining from using his Citi Bike membership or playing sports, lest he sustain an injury requiring medical care.
And when it's time to hire employees, he says he will most likely avoid the extra work of administering a company health insurance plan and instead encourage employees to shop the new health care exchanges on their own and bump up their salaries to cover the cost.
Research published in the journal Health Affairs showed that small businesses with 10 to 24 employees have paid 10 percent more than large ones for the same health care coverage, and that companies with fewer than 10 employees have paid 18 percent more until now. Small businesses' plans were also more vulnerable to rate increases; as a result, they often provided less coverage, if they offered it at all, resulting in a competitive disadvantage in hiring.
Constantia Petrou, owner of Konnectology, a website that provides information on health care specialists, expects the new law to broaden her hiring options. When she started her company seven years ago in Burlingame, Calif., she realized that she couldn't afford to offer a group plan.
''In terms of hiring, the health care expenses contribute a huge, huge component to your cost of operation,'' Ms. Petrou says. So instead of bringing on full-time employees, she relied on contract workers.
She is looking forward to getting price information online from the Small Business Health Options Program, or SHOP, an exchange that was created by the new law. (Currently, business owners can obtain estimated SHOP prices online, but specific ones are only available by mail after filling out and mailing in a PDF downloaded from Healthcare.gov. Some states, including California, have their own SHOP exchanges, and their procedures vary.)
Ms. Petrou says the law could enable her to hire full-time employees, depending on the new costs of coverage. If so, she will either pay for a portion of the individual plans that her employees shop for on the exchange, or she may take advantage of tax credits and offer a small group plan. ''We now have options to explore,'' she says.
Some experts say this type of flexibility may have a big impact on the economy over all.
''Assuming we get the website working, it's going to be the biggest step we've had in a long time in the U.S. in terms of changing the structure of the economy,'' says Craig Garthwaite, assistant professor of management and strategy at Northwestern University's Kellogg School of Management. Mr. Garthwaite is a co-author of one of two recent studies that conclude that the Affordable Care Act could spur entrepreneurship by easing job lock -- where people stay in a job mainly for the health insurance.
The act was aimed at people like Jeannie Armstrong, who in 2009 was planning to quit her job within a couple of years to start a private clinic for adolescents with substance-abuse problems. But then her 18-year-old son learned that he had diabetes. Fearing that he would be unable to find individual health insurance, she has stayed in her job so her son could keep receiving coverage under her employer's health plan.
''We're talking pre-existing condition, we're talking no money, we're talking health care costs out of the roof,'' Ms. Armstrong says of her son's situation.
But in January, her son will be eligible for individual health insurance. That will free Ms. Armstrong to quit her job as a social worker in the juvenile court system of Fairfax County, Va., and to pursue her entrepreneurial dreams. Now, instead of opening a for-profit clinic, Ms. Armstrong has decided to go the social-entrepreneurship route. In September, she founded the nonprofit Center to End Adolescent Substance Abuse Encounters.
Over the next year, she plans to stay in her job while her son finishes school; in her free time, she will assemble a board of directors and write the organization's bylaws. By next fall, she plans to be running the nonprofit full time.
''I'm not hamstrung by having to stay in this job,'' she says.
Ms. Armstrong sees the new law as an opportunity to start something new. But Kevin Kuhlman, manager of legislative affairs for the National Federation of Independent Business, says that while job lock is a real concern for entrepreneurs, he remains skeptical that the new law will be able to solve the problem.
The federation unsuccessfully challenged the constitutionality of the Affordable Care Act's requirement that most people obtain health insurance or pay a tax penalty, in a case that went all the way to the Supreme Court last year. The plaintiffs were uninsured and didn't believe that the government could require them to buy insurance.
Certainly, many established small-business owners are not clamoring for information on new health coverage. Barry Sloane, chairman and chief executive of Newtek Business Services, based in New York, says a majority of his customershaven't bothered to visit the exchanges.
''The negative publicity that's come out about the site not functioning has kept people from thinking they can go to it and get a result,'' Mr. Sloane says.
Some small businesses aren't shopping the exchanges because they don't yet need to, he says. Businesses with fewer than 50 people will not be required to offer health insurance; those with 50 or more employees will have to do so, but not until 2015.
Small-business owners are ''very confused and they're very concerned,'' Mr. Sloane says. And those feelings are only intensifying amid news reports that just a tiny number of Americans have enrolled in the exchange plans and amid questions about the government's ability to keep enrollees' personal information secure. ''The negative stigma around the Affordable Care Act is building steam,'' he says.
A new crop of Internet companies, meanwhile, is convinced that Americans will need help navigating the new health care landscape. Benefitter, for example, based in San Francisco, provides business owners and individuals with information on the new law's requirements.
The Young Entrepreneur Council, based in New York, is focusing on small-business owners and solo entrepreneurs with a website, StartupInsurance.com, that it founded in September. It offers health insurance plans from six carriers.
''Whether the government is in there or not, whether corporations are in there or not, this is a big void,'' Scott Gerber, the council's founder, says of health care insurance for the small-business market.
Jack Hooper is among those who see the law as a business opportunity. A former intelligence analyst for the federal government, he enrolled at the Wharton School of the University of Pennsylvania in 2012 and hoped to start a company after graduation. His wife, Brittany, was to provide financial support and health care benefits through her job while he got the business going, but when she became pregnant with twins, those plans collapsed.
As he began investigating his own health care options, he realized that the Affordable Care Act could provide more than just access to coverage for his family.
''What's been a very stagnant industry, health insurance, is being shaken up and people are starting to re-evaluate their plans,'' Mr. Hooper says. He anticipates that premiums will remain expensive, pushing many Americans to high-deductible plans, and that these people will need help in managing care-related expenses.
Last spring, he started a service called Command Health, which he describes as ''a Mint.com or TurboTax for high-deductible health insurance plans.''
Based on his previous experience working for the federal government, he says, he is not surprised by the problems that have emerged in the Healthcare.gov site. Entrepreneurs like him will end up providing the ultimate solutions to the problems that have emerged from the Affordable Care Act, Mr. Hooper says.
Mr. Jeyakumar of Skillbridge says of the law's rocky start: ''Being a tech entrepreneur myself, I appreciate that technology is often not perfect in the first release, and a lot of great products from Facebook to eBay were buggy when they first came out.''
He adds: ''I think the concept is good, and as with anything, it's a wait-and-see on execution. If it works, great, and if not, we will fall back on existing alternatives.''
URL: http://www.nytimes.com/2013/11/24/business/in-the-health-law-an-open-door-for-entrepreneurs.html
LOAD-DATE: November 24, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTOS: Jeannie Armstrong, left, a social worker, plans to leave a job that provides her son with health insurance and start a nonprofit now that her son, who has diabetes, can have his own policy under the new health care law. Jack Hooper, with his wife, Brittany, and twin sons, center, has started a service to help people navigate high-deductible insurance plans. And Rajeev Jeyakumar, an entrepreneur, will pay $74 a month, after tax credits, for his new insurance plan through the New York State exchange. (PHOTOGRAPHS BY DANIEL ROSENBAUM FOR THE NEW YORK TIMES
RYAN COLLERD FOR THE NEW YORK TIMES
CHESTER HIGGINS JR./THE NEW YORK TIMES)
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January 13, 2017 Friday
Late Edition - Final
Donald's Medical Delusions
BYLINE: By PAUL KRUGMAN
SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 27
LENGTH: 842 words
Thanks, Comey.
The Justice Department's inspector general is now investigating the way the F.B.I. director conveyed the false impression of an emerging Clinton scandal just days before the election, even as he said nothing about ongoing investigations into Russian intervention and possible collusion with the Trump campaign. That action very probably installed Donald Trump in the White House. And it's already obvious that the incoming commander in chief will be a walking, tweeting ethical disaster.
On the other hand, he's also dangerously delusional about policy.
Some Republicans appear to be realizing that their long con on Obamacare has reached its limit. Chanting ''repeal and replace'' may have worked as a political strategy, but coming up with a conservative replacement for the Affordable Care Act -- one that doesn't take away coverage from tens of millions of Americans -- isn't easy. In fact, it's impossible.
But it seems that nobody told Mr. Trump. In Wednesday's news conference, he asserted that he would submit a replacement plan, ''probably the same day'' as Obamacare's repeal -- ''could be the same hour'' -- that will be ''far less expensive and far better''; also, with much lower deductibles.
This is crazy, on multiple levels.
The truth is that even if Republicans were settled on the broad outlines of a health care plan -- the way Democrats were when President Obama took office -- turning such an outline into real legislation is a time-consuming process.
In any case, however, the G.O.P. has spent seven years denouncing the Affordable Care Act without ever producing even the ghost of an alternative. That's not going to change in the next few weeks, or ever. For the anti-Obamacare campaign has always been based on lies that can't survive actual repeal.
A prime example is the pretense that health reform hasn't helped anyone. ''Things are only getting worse under Obamacare,'' declared Paul Ryan, the speaker of the House, last week. Yet the reality is that there has been a dramatic reduction in the number of Americans without insurance since reform went into effect -- and an overwhelming majority of those covered by the new health exchanges are satisfied with their coverage.
How have Republicans nonetheless been able to get away with this lie? Part of the answer is that many of the newly insured don't know that they're being covered via Obamacare, or at any rate don't realize that they will lose coverage if it's repealed.
But that will change if repeal proceeds. For example, the percentage of nonelderly white adults without insurance fell by almost half from 2010 to 2016, from 16.4 to 8.7, a gain surely concentrated in the Trump-supporting white working class. Repeal would send that number right back up, and there would be no hiding the damage.
Meanwhile, Republicans have made hay over this year's increase in insurance premiums. But this looks very much like a one-time adjustment; and the broader picture is that health costs have actually gone up much more slowly since Obamacare was enacted than they did before, in part due to the law's cost-control features, which have worked far better than most expected.
And if the Affordable Care Act is killed, myths about its costs will be replaced by the reality of soaring bills for millions of Americans who don't realize how much the act has helped them.
But won't Trumpcare solve all these problems, by offering something much better and cheaper? Not a chance.
Republicans don't have a health care plan, but they do have a philosophy -- and it's all about less. Less regulation, so that insurers can turn you down if you have a pre-existing condition. Less government support, so if you can't afford coverage, too bad. And less coverage in general: Republican ideas about cost control are all about ''skin in the game,'' requiring people to pay more out of pocket (which somehow doesn't stop them from complaining about high deductibles).
Implementing this philosophy would deliver a big windfall to the wealthy, who would get a huge tax cut from Obamacare repeal, and it would mean lower premiums for a relatively small number of currently healthy individuals -- especially if they're rich enough that they don't need to worry about high deductibles.
But the idea that it would lead to big cost savings over all is pure fantasy, and it would have a devastating effect on the millions who have gained coverage during the Obama years.
As I said, it looks as if some Republicans realize this. They may go ahead with repeal-but-don't-replace anyway, but they'll probably do it because they believe they can find some way to blame Democrats for the ensuing disaster.
Mr. Trump, on the other hand, gives every impression of having no idea whatsoever what the issues are. But then, is there any area of policy where he does?
Read my blog, The Conscience of a Liberal, and follow me on Twitter, @PaulKrugman.
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URL: http://www.nytimes.com/2017/01/13/opinion/donald-trumps-medical-delusions.html
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July 13, 2011 Wednesday
Doing the Math on Employer Health Insurance
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1164 words
HIGHLIGHT: Will the new health care law prompt employers to drop health coverage?
Our post last month on the McKinsey & Company study that suggested - but absolutely did not predict - that up to 30 percent of employers would shed the health insurance plans they now provide workers in 2014, when the Patient Protection and Affordable Care Act largely takes effect, drew some readers into an interesting discussion. After one reader wondered what prevents those companies from dropping health insurance now, another, adam of Washington, wrote a thoughtful response that is worth reprinting at length. The premium calculator he describes was developed by the Kaiser Family Foundation and allows users to enter demographic data and generate an estimate for how much insurance will cost when purchased on the exchanges created by the health care overhaul. Here's what adam wrote:The employee's desire for health insurance is what's stopping them from dropping coverage now. Employees don't want to be left to the individual market with its high premiums, pre-existing conditions limits, after tax premium payments, etc. Employers don't want to lose good employees because their compensation packages aren't competitive. But PPACA completely changes that calculation since it gets rid of the disadvantages in the individual market. In fact, the individual market will be the better option for many people. Say that in 2014 your employer offered you a raise that was equal to the employer's cost to provide you with family plan minus the $2,000 penalty*, in exchange for giving up your employer provided health insurance. Since it's 2014, there would now be an exchange for you to buy health insurance. Would you take that deal?
Let's put some real world numbers on it. I'm using this calculator: http://healthreform.kff.org/subsidycalculator.aspx. Say you are 50, married with two kids, make $70,000 annually, and in a medium cost region. Your employer plan costs $16,858 per year, of which your employer pays a fairly typical 75 percent, or $12,643, so your premium share is $4,214. You net $65,786. So your employer says he'll give you a raise of $10,000 if you forgo employer provided health insurance. The employer pays the $2,000 penalty and pockets the $643 difference. Now you have to get health insurance. You now have salary of $80,000 thanks to that raise. You go to your health insurance exchange and find out that you're eligible for a premium tax credit of $9,258, so you pay $7,600. You net $72,400. So thanks to the PPACA, your employer can drop insurance, and he'll be $643 better off and you'll be $6,614 better off.
That's why employers won't drop insurance now, but will in 2014.
If only things were that simple. Permit The Agenda to introduce a few complications.
First, adam has ignored the impact of taxes. Thanks to a quirk of tax law, when an employer pays insurance premiums for an employee, the employee pays no taxes on the benefit. But if the employee were given the cash equivalent of the employer's premium obligation, that would be taxed as income. So to use adam's example, the employee who trades his insurance for a $10,000 raise will have to surrender 35 to 40 percent of that in taxes (25 percent federal tax, 7.5 percent for Social Security and Medicare, plus state and perhaps local taxes). So now, that $10,000 is worth only $6,250, and the employee is only up $2,864. Meanwhile, the employer is actually worse off - the extra $10,000 in salary will cost $750 in Social Security and Medicare, so instead of being up $643, it's down $107.
If our hypothetical employer wanted to come out ahead by $500 (which would save a company with 100 employees $50,000), he'd have to limit the raise to $9,435. This would be worth $5,897 to the employee, who would now be better off by $2,511.
That's hardly a windfall, but it's still a pretty good deal, no? Well, maybe, but maybe not. In his comment, adam supposes that the premium costs for insurance purchased on the exchange for any given individual (as estimated by the Kaiser calculator) will be about the same as the premium cost for employer-sponsored insurance. That could well be true, said Gary Claxton, a Kaiser Family Foundation vice president who helped design the calculator, but it depends on how the government interprets one nuance in the law.
The Affordable Care Act requires that insurance purchased on the exchange deliver certain minimum benefits, but it is silent about whether large employer plans will have to meet the same standards, according to Mr. Claxton. The government, he said, will have to address this in the regulations that flesh out the law. If the requirements for exchange plans are more stringent than those for employer plans, they will probably cost more, which would make it harder for the raise an employer offers in place of coverage to meet the cost of buying coverage on the exchange.
Finally, a cash deal that looks good in the first year may turn out to be less generous in succeeding years, according to Mark Combs, a consultant with Gallagher Benefit Services in Mount Pleasant, S.C. That's because the cost of health care is increasing faster than inflation. "The financial reality is that the costs are still there and are still going up," said Mr. Combs. "Let's say you get a 10-percent increase - that's the rough health care trend right now - then for that person the premium will go up $1,600. And the employer has washed their hands of it - they're out of the business."
Few employers seem willing to wash their hands of it yet, said Jody Amodeo, a health care consultant with Thomson Reuters, which advises around 300 large employers on the issue. "Of our clients, none of them have alluded to dropping coverage," she said. "We're not seeing 30 percent. We're not even seeing five percent. We have not heard that from one client."
"People shouldn't pretend that they know what's going to happen with any real degree of certainty, until some of the parameters have been established," said Mr. Claxton. "The alternative market we're talking about just doesn't exist anywhere yet, so we don't know what it looks like. And we don't know how much confidence people will have in it."
*Note from The Agenda: The Affordable Care Act levies a penalty on companies with more than 50 full-time employees if any of those employees receive a government subsidy to buy health insurance on the exchange. The penalty is the lesser of either $3,000 for each employee subsidized by the government or $2,000 for all full-time employees, minus a 30-employee discount.A second consideration: People with employer-sponsored insurance can pay their share of their insurance premiums with pretax income, by using their flexible spending account. Those who purchase individual insurance have no such option.
Debating Whether Businesses Will Continue to Offer Health Insurance
How the Health Care Law Affects Your Business
Is the Health Care Plan a Good Thing?
Looking to the Affordable Care Act For Help
Small Firms May Not Keep Current Health Plans After White House Decision
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October 24, 2011 Monday
New Leader for Liberal Research Group
BYLINE: CATHERINE RAMPELL
SECTION: BUSINESS; economy
LENGTH: 373 words
HIGHLIGHT: A veteran of the Obama and Clinton administrations, Neera Tanden, will lead the Center for American Progress, whose progressive viewpoint reflects a disaffected element of President Obama's base.
A veteran of the Obama and Clinton administrations, Neera Tanden, will be taking over as president of the Center for American Progress, a research organization that represents the views of the president's more liberal, and somewhat disaffected, base.
She will succeed John Podesta, who ran President Obama's transition team and served as White House chief of staff to President Clinton, on Nov. 1. Mr. Podesta will remain at the organization as non-executive chairman of the board.
In an interview on Monday, Ms. Tanden said she hoped "big ideas," both from her organization and other progressives, would help unite the left in the year leading up to the next presidential election. Recent national polls show that Mr. Obama is behind the Republican candidate on a generic ballot.
"There's a lack of faith in our ability to solve large-scale problems together, and that weakens the progressive cause," she said. "There's big hunger for bigger solutions, and some of the reaction we're seeing in this country is a rejection of the current discourse in Washington."
She said she believed that Mr. Obama's recent push for more economic stimulus intended to create jobs may be winning him back more liberal supporters who had felt alienated by his push for austerity measures.
Ms. Tanden is the chief operating officer at the Center for American Progress, and served as senior adviser for health reform at the Department of Health and Human Services, where she helped shape the Affordable Care Act. She said that despite continuing criticism of the health care legislation passed last year, she did not anticipate that Congressional Republicans would make a serious attempt to dismantle it before the next election.
"There were two moments where Republicans had had levers over the Senate and the White House to dismantle the Affordable Care Act," she said. "One was the government shutdown, and the other was the debt limit deal. In neither case did they use those levers to destroy the Affordable Care Act."
What Are Social-Impact Bonds?
How Stimulating Is the Tax Cut-Jobless Benefit Deal? Part II
Just How Stimulating Is the New Tax Cut-Jobless Benefit Deal?
Podesta Joins Club Wagner
Where Will the Stimulus Money Go? A State-by-State Breakdown
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The New York Times
May 11, 2015 Monday
Late Edition - Final
Report Says Federal Cuts Will Hurt Public Hospitals
BYLINE: By ANEMONA HARTOCOLLIS
SECTION: Section A; Column 0; Metropolitan Desk; Pg. 20
LENGTH: 666 words
New York City's public hospital system is looking at a major cash squeeze within four years if federal cuts to hospitals serving large numbers of poor and uninsured patients take place as scheduled, according to a report by the city comptroller, Scott M. Stringer, to be released on Monday.
Beginning in 2017, the federal government will begin cutting subsidies to those hospitals, based on the theory that since the passage of the Affordable Care Act, which has insured millions of Americans, hospitals will no longer need the same level of subsidies for uncompensated care.
But Mr. Stringer's report says that the city's hospital system will not benefit as much as expected from the Affordable Care Act insurance plans because the system continues to serve a high proportion of undocumented immigrants, who are not eligible for coverage under the act.
In the health law's first year, the number of uninsured patients the system treated dropped by only 1.3 percent, the report said; another decrease of 7.2 percent is projected by 2019.
More strikingly, the city's hospital system has not attracted enough newly insured patients to give it the revenue increase it would need to make up for the loss of federal funds, the report says.
''We have a solemn commitment to fund H.H.C. so that it can serve everyone who walks through the door, regardless of their immigration status or ability to pay,'' Mr. Stringer said in a statement, referring to the Health and Hospitals Corporation, which runs the public hospitals. ''That's why we need to find a real cure for these cuts, not just apply a Band-Aid.''
The 11-hospital system expects to face a deficit of more than $1 billion in fiscal year 2017, which will grow in subsequent years, the report said. The city's taxpayers are ultimately responsible for filling that gap.
The report projects that the system's cash on hand, an indicator of financial stability, will drop to $44 million, from $1 billion, by 2019-2020, largely because of the projected $827 million loss in federal ''disproportionate share'' subsidies.
Dr. Ram Raju, president of the hospitals corporation, said he was working with the city to mitigate the cuts. He said he was also trying to persuade the state to change its methodology for financing charity care, which he said put the corporation ''last on the line.''
He agreed that undocumented immigrant care was a problem. ''The Affordable Care Act did not bring in everybody,'' Dr. Raju said. ''It left behind a group of people. They have no way of getting insurance, and most of them are served by our system.''
The three hospitals most affected by the burden of caring for uninsured immigrants are Lincoln Medical and Mental Health Center in the Bronx, Elmhurst Hospital Center in Queens and Woodhull Medical and Mental Health Center in Brooklyn, the report said.
City officials have long predicted that the cuts would hurt New York City more than other parts of the country because of its large number of immigrants.
But the report raises another surprising factor: the failure of the hospitals corporation's entry into the state's Affordable Care Act exchange to produce as much revenue as expected.
The hospital system was counting on its MetroPlus insurance plan, newly sold on the state exchange, to attract young people of modest means to city hospitals, despite their image as a last resort for the poor. But MetroPlus has not been as successful as expected, with about a third of the 45,000 new subscribers dropping out within the first year, the report said, adding that the decline was because members failed to pay their premiums, among other reasons.
Mr. Stringer said that revenue from new enrollment in MetroPlus was expected to offset only about 28 percent of the federal cuts.
The report calls on the federal government to delay the cuts until their impact can be better assessed, and for the state government to explore the feasibility of using its own funds to cover undocumented immigrants.
URL: http://www.nytimes.com/2015/05/11/nyregion/federal-cuts-would-be-major-blow-to-new-york-citys-public-hospitals-comptroller-says.html
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August 25, 2014 Monday
A Business Owner Stands By Zane Benefits' Controversial Health Insurance Plan (for Now)
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1019 words
HIGHLIGHT: Mr. Baller remained committed even after his own accountant spoke to a lawyer, who came back vehemently opposed to the idea.
In June, we reported on the controversy surrounding Zane Benefits, a company that has won over many small businesses by promising them that they can cancel their group health insurance plan and still offer their employees a health benefit. Zane sells software that helps small businesses reimburse workers - with tax-free dollars! - when they buy their own individual insurance policies.
At least that is how it has worked so far. All of the lawyers and other experts we interviewed for the story told us that Zane's plan is probably not legal - or if it is, it will not be for long.
By coincidence, hours before that story was published, we received an email from Clinton Baller describing his own experience with Zane. Mr. Baller had long offered group insurance to his four employees (and himself) at Avid Payment Solutions, a credit card payment processing company in Birmingham, Mich. But late last year, his renewal notice prompted him to go looking for insurance on the new individual exchange created by the Affordable Care Act.
"My personal premium was going to go from $2,100 to $2,500 a month," he said. "And one of my employees - she had a two-person policy, and she was going to go to $2,000, and I was contributing half." (Mr. Baller said that the increases for 2014 were no higher than the increases he had experienced in recent years, before the Affordable Care Act kicked in.) On the exchange, his employee found a policy that, after a subsidy provided through the law, would cost her only $150 and him $500 a month. When he learned about Zane and its promise that he could provide tax-free employer contributions, individual insurance seemed too good to pass up.
At the same time, Mr. Baller's sales manager, a former health insurance agent, got word that the state's Blue Cross/Blue Shield company was paying 3 percent commissions along with a $300 bonus for each individual policy an agent brought to the carrier - even if it was purchased on the government exchange. This, too, seemed irresistible, especially when packaged with Zane, which also pays a commission to agents who sell the company's software. So he started another company, an insurance agency, to sell employers on the Zane arrangement and employees on individual insurance.
"You can't look at the A.C.A. and not realize the opportunity that is there," Mr. Baller said recently. "So the opportunity that we saw was not only to go out and sign up individuals, but to talk to businesses like mine that are being crushed by the premiums." If they succeeded, they'd profit on two fronts: first when the business signed up with Zane and dropped group health insurance and then when the employees purchased their own insurance through his agency, the Baller Group.
He also decided to try to sell in the individual market, in particular to low-income African-Americans in Detroit, whom he figured are likely to be open to the health law, widely known as Obamacare, and to qualify for the subsidies that make it truly affordable. In this effort, the Baller Group uses the name 855-BAMA.
But at about the time we were reporting the article about Zane, Mr. Baller started hearing the same doubts about whether the Zane plan was legal. So where does that leave him?
In the late spring, Mr. Baller went back to Zane, several times. "I pressed them really hard," he said. "They insist up and down what they're doing is legit. And frankly I believe it, because otherwise they'd be shut down by now. And the people who are mostly arguing against it are the incumbents, who stand to lose when businesses decide to convert from group coverage to independent coverage."
Mr. Baller remained committed even after his own accountant spoke to a lawyer, who came back vehemently opposed to the idea. Mr. Baller chose not to talk to a lawyer himself. "First of all, lawyers are just going to cost a lot of money and to evaluate something I'm pretty able to evaluate on my own," he said. "And it's not settled. I don't think anyone can definitely say yes, it's legal, or no, it's not."
Still, he does suspect that even if the Zane plan technically passes legal muster now, the Internal Revenue Service may well revise its rules to foreclose any opportunity for an employer to provide tax-free reimbursement for individual insurance.
As it happens, it's not an issue that has come up with a prospective client: the Baller Group has yet to convert any businesses from group coverage, though it has signed up 875 individuals. "Businesses don't feel enough pain yet," he said. "There isn't this massive realization that there's this alternative. So many of these business guys are Republicans who are so ideologically opposed to Obamacare that they're blind to the fact that it's law of the land, and the opportunities that are inherent to it." Suffice to say, he will not be making his case to business owners as 855-BAMA.
Mr. Baller thinks the day of reckoning may come in October, when small-business owners get their renewals for next year and perhaps face the kind of sticker shock he did. So what will he tell them about the chances that the Zane approach will survive legal challenge? "I would just be personally honest with small businesses and say you could do it either way" - using either pre-tax dollars or post-tax dollars. And he said he would advise them that some lawyers think the strategy is illegal: "We're going to be very careful about making representations about what these people are getting into."
As for his own company, Avid, Mr. Baller said he plans to wait until the end of the year before he decides whether his own contribution will be pretax or post-tax. He may decide to do it post-tax even if the I.R.S. does not rule on the issue this year. Giving his employees raises to cover the tax obligation on policies bought on the individual exchange will still save him money over a group plan.
"If you're in a smaller group - three or four people - and they're all in their 50s, like our group, the policy premiums are high compared with an exchange policy," he said. "Plus I can give my employees choice over what kind of policy they want."
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The New York Times
December 23, 2016 Friday 00:00 EST
What Health Care Disaster?;
Letter
SECTION: OPINION
LENGTH: 58 words
HIGHLIGHT: A doctor asks, If Donald Trump believes that Obamacare is a disaster, why are record numbers signing up for it?
To the Editor:
Re "Sign-Ups Jump as Health Law Faces Repeal" (front page, Dec. 22):
Donald Trump and his Republican colleagues call the Affordable Care Act a failure and a disaster, yet record numbers of Americans are signing up for it.
What do these Americans know that Mr. Trump et al. don't?
DANIEL FINK
Beverly Hills, Calif.
The writer is an internist.
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January 2, 2014 Thursday
Times Minute | Milestone for Obamacare
BYLINE: Flora Lichtman
SECTION: MULTIMEDIA
LENGTH: 59 words
HIGHLIGHT: On the Minute, the impact of the Affordable Care Act on patients, physicians and the political landscape.
In the Video
Consumers Start Using Coverage Under Health Law
Previously on the Minute: Rescuing a Stranded Ship
The New York Times Minute features top headlines from The Times throughout the day, beginning at 6 a.m. Eastern.
Times Minute | Easing a Health Law Rule
Times Minute | New Poll on Health Care
The New York Times Minute
The New York Times Minute
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November 6, 2013 Wednesday
A Small Business Starts to Navigate the Affordable Care Act
BYLINE: PAUL DOWNS
SECTION: BUSINESS; smallbusiness
LENGTH: 952 words
HIGHLIGHT: In my renewal package, I found two crucial pieces of information that I never would have had without the Affordable Care Act.
Last week, I took a phone call from Maggie, my health insurance broker. "I'm calling my clients who are getting big increases this year," she said. "I didn't want to just send an email."
Great. I cut to the chase: "How much?"
"Thirty-three percent, for comparable coverage," she said.
My first reaction, as you might expect, was, "Thanks, President Obama." I realized, however, that wallowing in anger wasn't going to do me or my employees much good, and I decided that I needed to think rationally about this.
It has been more than three years since the Affordable Care Act passed, and in that time my insurance situation has been tolerable. Even though I pay my people too much to qualify for a tax credit, my rates actually declined the last two years. I suspect that this is because an older worker with a lot of health issues quit. But I never confirmed that that had anything to do with it. In all of the years before 2010, my rates went up, often by a lot and again for reasons that were unclear to me.
In three of the last nine years - 2005, 2006, 2009 - my insurance rates increased more than 20 percent. The increase in 2006 was the worst, a bump of 29 percent. So a large increase is something I have experienced before, especially in the years before the new law passed. Random, excessive cost increases seemed to be baked into our system.
My phone call with Maggie left me with a lot of questions, particularly about the details of what was being offered for all of that money. A renewal package arrived by email the next day. It looked a little different from what we had received in previous years, and at first that confused me. We used to get an enormous Excel sheet, with tabs for the current policies, with renewal options, and with the steps required to renew spelled out. The new format was a large pdf, and it didn't include a checklist of steps to renew.
But after careful examination, and a couple of phone calls to Maggie, I realized that I was going to have a lot more information to work with in deciding what to do next. In the past, the renewal was a crap shoot. Rates went up, rates came down, but I never got an explanation for the changes and couldn't predict what might happen the following year. And I never knew whether the plan I chose for myself and my workers was relatively good or relatively bad. My impression was that I was getting something on the cheap side, simply because it was an H.M.O. and the co-pays went up every year.
But in my renewal package I found two crucial pieces of information that I never would have had without the Affordable Care Act:
I can see at a glance how my plan ranks in the universe of choices: I had already received notice, in September, that our current plans were going to be replaced with new ones that conform to the A.C.A.'s metal rankings, but I hadn't been told which level was closest to our current plans. The renewal package cleared up the confusion: we had been buying a gold level plan. How about that! And, even better, the coverage levels that correspond with each metal level are mandated by law, so that I can now comparison-shop plans offered by different providers with some confidence that I'm comparing apples to apples.
I now have a breakdown of the cost of covering every individual in my group: The renewal package gave a different cost number for every worker, along with spouses and children. I asked Maggie where these numbers came from, and she told me that the rates are derived from four pieces of information: age, sex, ZIP code and tobacco use. This is a huge change, and in fact, it's one of my wishes come true. The old system discouraged the hiring of older workers.
In past years, my agent told me, our renewal rates took into account only the health of people within my company's group. A sick worker, or a dependent, might drive up the cost of insuring the whole group. Apparently, those days are gone. The new risk pool is everyone in the region whose characteristics match each other.
In the old system, every person in my group fell into one of three tiers - single, couple, family with children - and everyone in the same tier paid the same rate. For the families, the cost of insuring two children was the same as insuring six. Every person with single coverage was charged the same rate, whether they were 20 years old or 60. In the new system, everyone is paying per individual, and those rates vary by age and tobacco use. Now it's cheaper for the young and (presumably) healthy, and smaller families don't subsidize the larger.
With a clear way to compare plans, and a way to price individuals in my group, I can now start shopping for alternatives to the first quote I was given - the one with the 33 percent price increase. Maggie told me that my local market, Philadelphia, is dominated by two companies: Independence Blue Cross (our current provider) and Aetna. All of the pricing that was in our package was from Independence Blue Cross. She offered to get quotes from Aetna, and I told her to go ahead.
That will take a few weeks. But I don't necessarily need to wait for her to get back to me. Surely, the new federal website, Healthcare.gov, will make it easy for me to shop for plans, right? Well, sort of.
In my next post, I'll tell you what happened when I tried to shop online.
Paul Downs founded Paul Downs Cabinetmakers in 1986. It is based outside Philadelphia.
A Business Owner's First Brush With HealthCare.gov
Why Labeling Health Plans Gold, Silver or Bronze Doesn't Help
Another Delay for Small-Business Health Exchanges? Depends on Whom You Ask.
Following Up on Our Sales Training, Profit-Sharing, Health Insurance and the Shutdown
What Does the Affordable Care Act Mean for Your Business?
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(Economix)
March 6, 2013 Wednesday
Health Reform, the Reward to Work and Massachusetts
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 925 words
HIGHLIGHT: Even if health care reform in Massachusetts has had a limited effect on employment, the impact of the Affordable Care Act on the national labor market is likely to be large, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
The United States labor market is in for a shock when health reform is fully carried out, regardless of what employers decide about health insurance or how smoothly reform might have unfolded in Massachusetts.
Beginning next year, millions of Americans will be eligible for generous subsidies in the form of cash assistance to pay for their health insurance premiums and out-of-pocket health expenses pursuant to the Affordable Care Act. The subsidies will sharply reduce the financial reward to working because they will be phased out with household income.
As the Princeton economists Alan B. Krueger, who has held positions in the Obama administration, and Uwe E. Reinhardt, my Economix colleague, explain, health insurance premium assistance "would present millions of low-income American families with total marginal tax rates in excess of 75 percent." They add, "Such high marginal tax rates may well make unemployment and welfare an attractive alternative to working."
It would appear that, together with per-employee penalties levied on employers, the new law's health insurance subsidies could significantly affect the labor market.
Most workers are offered affordable health insurance by their employers, and the new law will consider them ineligible for subsidies and will not ask their employers to pay any penalty. You might guess that the aggregate labor-market impact of the law could be small, because the penalties and subsidies would not apply to the majority of the work force "covered" by employer health insurance.
But it is wrong to assume that the law will have little effect on the reward to working among covered workers. Their employers could drop coverage, or the employee could switch to a job without coverage. More important, the subsidies are available to the unemployed and others who do not work, even if their previous jobs had provided coverage. If and when they go back to work in a covered job, federal law will welcome their return by taking their subsidy away.
Yet another reason that covered workers will experience high marginal tax rates like those noted by Professors Krueger and Reinhardt is that the subsidies will be available to family members on the basis of the employee's income, in combination with his or her spouse's income, if any.
The Department of Health and Human Services says there is no reason for alarm because the experience in Massachusetts since 2006 shows "that the health care law will improve the affordability and accessibility of health care without significantly affecting the labor market," as I noted last week, referring to a Washington Examiner report.
For those worried about dire labor market consequences of the federal law, Jonathan Gruber of the Massachusetts Institute of Technology replies (at 27:32 in this video): "We've actually run this experiment, folks, we ran it in Massachusetts. O.K. In Massachusetts, we put in a system with more generous subsidies than the federal government is doing."
When it comes to quantifying the new federal law's penalty on employment, Professor Gruber and Health and Human Services are incorrect to take comfort in the Massachusetts experience since 2006. As I explained last week, the federal law's employer penalty is more than tenfold the Massachusetts penalty. In other words, if the Massachusetts penalties pushed down workers' wages by 16 cents an hour, the federal penalties would push them down $1.67.
Professor Gruber is also incorrect that the federal law is introducing less generous subsidies than the Massachusetts law did. Federal subsidies will be available for people laid off from their jobs, but the new Commonwealth Care subsidies in Massachusetts are not, because Commonwealth Care excludes people eligible for the Medical Security Program (a longstanding program providing health benefits to Massachusetts people receiving cash unemployment benefits).
Moreover, people leaving a job with health insurance have to wait six months before they can enter Commonwealth Care.
Commonwealth Care also excludes children: if a Massachusetts resident wants health insurance subsidies for his or her children, Medicaid is the primary option. The federal law has no such restriction: it allows Americans to receive subsidies while enrolling their entire families in the same health plan as, say, the United States senators representing their states.
Indeed, many consumers may perceive Commonwealth Care to be an extension of Medicaid. When it began, Commonwealth Care consisted of four plans offered by the state's Medicaid Managed Care Organizations (a fifth plan has recently been added). Perhaps that's why only 158,000 people were enrolled in Commonwealth Care as of 2011, which is less than 10 percent of the people in Massachusetts whose family income fell in the interval required by the program.
In contrast, recipients of federal subsidies will be receiving cash they can spend on a plan of their choice: that's a lot more generous than helping people join Medicaid.
For all these reasons, economic reasoning points to a contraction of the United States labor market as the full Affordable Care Act is carried out, regardless of what may have happened in Massachusetts.
Older Workers Could Benefit if Companies Drop Insurance
In Massachusetts We Trust
Health Care Aside, Fewer Jobs Than in 2000
Further Reading on Mr. Mandate
Health Reform Comic Book
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August 7, 2012 Tuesday
The Affordable Care Act Rebate Checks Are in the Mail: Now What?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 1267 words
HIGHLIGHT: Small-business owners are receiving millions of dollars in rebates thanks to the health care overhaul. What these owners can do with the money is not entirely clear.
Some small businesses were among the most strident opponents of the Affordable Care Act, but by Wednesday, many of these businesses will have received checks totaling $321 million from their health insurance providers, courtesy of the health care overhaul that became law in 2010. The checks are rebates from insurers that did not spend at least 80 percent of the premiums they collected from small group plans on either actual health care expenses or improving the quality of health care, a provision known as the medical loss ratio rule.
Small businesses in 38 states, the District of Columbia and three United States territories are receiving checks on behalf of their employees, according to the Department of Health and Human Services. (In the remaining 12 states and in the Northern Mariana Islands, insurance companies in the small group market spent at least 80 percent of collected premiums on health care-related expenses.) The typical subscriber, which could be either an individual or a family, will receive a $174 rebate. Average rebates are highest in Georgia, at $811 per subscriber, and lowest in Utah, at $7 per subscriber.
The extent to which an employer can keep the rebate depends on whether under the terms of the health plan, the rebate is considered a plan asset: if it is a plan asset, then under the Employee Retirement Income Security Act of 1974, known as Erisa, it must be used for the benefit of the people participating in the health plan. Generally speaking, a private company is entitled to keep the share equivalent to its contribution to its employees' insurance costs, said a Labor Department spokesman who requested anonymity, and is required to allocate the rebate to plan subscribers in the same proportion as those employees' premium contributions. Beyond that, an employer, as a fiduciary for the health plan, must "act prudently, solely in the interest of the plan participants and beneficiaries, and in accordance with the terms of the plan," according to guidance for employers from the Labor Department.
The allocation must also be impartial. "In deciding on an allocation method, the plan fiduciary may properly weigh the costs to the plan and the ultimate plan benefit as well as the competing interests of participants or classes of participants provided such method is reasonable, fair and objective," according to the guidance. An employer could distribute the rebate among employees participating in the plan in the year the plan was overcharged, or it could distribute the rebate among current plan participants. Alternatively, according to the guidance, it can apply the rebate "toward future participant premium payments or toward benefit enhancements."
Lawyers who specialize in employee benefits law disagree on the implications for small businesses. But Priscilla E. Ryan of the law firm Sidley Austin in Chicago said companies might be better off allocating all of the rebate to the benefit of their employees. "The easiest thing to do is just have the money be used for plan participants, and not say part of it is coming back to the employer, because that's just too complicated," Ms. Ryan said. "You're going to have people who have individual coverage, and people with plus-one coverage, and people with family coverage. The subsidy that the employer gives to each of those coverages is different. I would not want to be figuring out how much is going to be coming back to the employer for that reason."
The law also requires insurers to notify individuals enrolled in plans entitled to rebates of the coming windfall - no doubt as a way to build popular support for the overhaul - something that is sure to raise expectations among employees. But those waiting for a check in the mail may end up disappointed: the rules and regulations to carry out the law give companies pretty broad discretion to decide how to spend the money on their workers' behalf, according to lawyers who specialize in employee benefits, and few are likely to actually cut checks to their employees.
Both Ms. Ryan and Mark A. Bodron, a lawyer with the Baker Botts firm in Houston, said that companies, having decided how much of the rebate to allocate to plan participants, would find it easier and cheaper to plow the proceeds back into the plan. The simplest option is to decree a "premium holiday" the next time employee premiums are due, and offset as much of the employee contributions as the rebate affords.
But could a business actually hold the rebate until next year and use it to offset some of its own contribution to employee premiums - that is to say, effectively pocket the money for itself? After all, the company could argue that without the rebate, it simply could not afford to pay the same share of its employees' health coverage - that the rebate, in other words, kept the employees' premium contribution from going up. Ms. Ryan said a company could do this.
"There is no technical definition of employees' share," she said. "The employer is under no obligation to offer health coverage, and if the employer does offer health coverage, there's no obligation to subsidize any particular portion of the premium. You can use the rebate to keep the employees' contribution level."
Other lawyers were more cautious. The Labor Department has not given clear guidance on that, and "in the absence of the guidance, that's a position you could take," said Chris Rylands, a lawyer in Atlanta with the firm Bryan Cave. "I would make sure that if you're going to do anything beyond an immediate premium holiday or cutting a check that you document it thoroughly and you seek advice of counsel. Because it's an area where there's risk, you ought to think hard about it before you play too many games."
Mr. Bodron was still more skeptical. "I don't think you want to hold the money that long, because I think that raises additional issues," he said. "The employer would have to worry if there's a prohibited transaction, because the employer has use of the money" for that period. And, he added, "to the extent that these are for the benefit of the participants, I don't think you want to do that. At the end of the day, employers are going to need to feel comfortable that if the Department of Labor were to look at what you did with the premium rebate that you met your fiduciary duties." An employer who breached those duties could face lawsuits from employees and the Labor Department, he said, and possibly even criminal prosecution.
But Mr. Bodron said that under Erisa law, it might be possible for an employer that holds the policy on a health plan to craft legal documents that specifically exclude rebates from the plan's assets. Such a move, he said, could be risky. "Generally, the plan documents control, and if the plan documents clearly say the rebate is not a plan asset, then arguably the employer may take the position you don't allocate any portion to the employees," Mr. Bodron said. "It will be interesting to see if an employer goes down that route and what the response would be from employees and the Labor Department."
Mr. Rylands said that he expected the government to tighten the rules eventually. "As we get further down the road," he said, "I think the Department of Labor will issue clearer parameters about what you can and can't do with the money."
Having Lost the Health Care Battle, the N.F.I.B. Readies for a Long War
Business Owners Try to Make Sense of Health Care
Is Dividing a Company the Way to Beat the Affordable Care Act?
Doing the Math on Employer Health Insurance
Debating Whether Businesses Will Continue to Offer Health Insurance
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November 6, 2014 Thursday
Assessing One Possible Change to the Affordable Care Act
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 385 words
HIGHLIGHT: The Save American Workers Act would raise the threshold for full-time work — and eligibility for employer-sponsored health insurance — from 30 hours to 40 hours a week.
In the wake of the resounding Republican victory in Tuesday's midterm elections, there has been much talk about bipartisan changes Republicans might want to make to the Affordable Care Act. On Wednesday, The Times reported on one possibility that could affect small businesses:
"Another group of Republicans and Democrats has also called for returning the health law's definition of full-time work to 40 hours from 30, arguing that the lower limit is forcing too many people out of work because of employers' efforts to comply with the law. Mr. Boehner [John A. Boehner, the House speaker] singled out that measure as one that he would like to see advance." (Another frequently suggested change would repeal a tax on medical devices.)
The bill in question is the Save American Workers Act, which would raise the threshold for full-time work - and eligibility for employer-sponsored health insurance - from 30 hours to 40 hours a week. We have discussed this bill in this space before. After a hearing in January, when testimony from the star witness - a business owner from Maine - was more symbolic than accurate, the measure moved quickly to the House floor. In early April, it passed the House.
But the legislation was only modestly bipartisan then. And it promises to be even less so should the Republicans bring it up next year, hoping to see it sail through the Republican-controlled Senate and land on President Obama's desk.
The Save American Workers Act was sponsored by a Republican, with 220 co-sponsors, nearly all of whom were fellow Republicans. Only seven co-sponsors were Democrats, and just three of them will return to the House in January. Two were defeated on Tuesday. Two more retired under siege, and their seats will also turn over in January.
When the bill came up for a vote in April, 11 more Democrats joined the seven Democratic co-sponsors and nearly the entire Republican caucus to give their assent. Two of these Democrats lost their bids for re-election outright; four more are trailing their Republican challengers in elections that were not settled as of Wednesday night. Another was leading in a close, as yet uncalled race.
In all, of the 18 Democrats who voted for the Save American Workers Act, it's possible that as few as seven would be in a position to vote for it again next year.
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July 9, 2014 Wednesday
Democrats Will Vote to Undo the Hobby Lobby Decision
BYLINE: DAVID FIRESTONE
SECTION: OPINION
LENGTH: 411 words
HIGHLIGHT: It’s a message bill, but at least it’s a clear one.
The Supreme Court's ruling last week in the Hobby Lobby case wasn't based on a fundamental right found in the First Amendment or anywhere else in the Constitution. When the justices said that closely held corporations have religious rights that let them refuse to pay for insurance plans that cover contraceptives, they based their decision on a 1993 law passed by Congress, the Religious Freedom Restoration Act.
That means Congress has the ability to rewrite federal law to overrule the court's decision, and Senate Democrats have wasted little time coming up with a bill to do just that.The bill, sponsored by Patty Murray of Washington and Mark Udall of Colorado, was introduced today, co-sponsored by 38 other Democrats. It wouldn't rewrite the 1993 law, which was intended to protect the religious rights of individuals. But it would make it clear that the law doesn't permit employers to refuse to comply with the Affordable Care Act, which requires contraceptives to be covered by health insurance.
It would be illegal for employers to cite a religious reason for disobeying the health law, as Hobby Lobby did. The only exception would be for houses of worship and religious non-profits, which have already been granted an accommodation by the Obama administration. (The Supreme Court seemed willing to undermine that accommodation, too, in an order released last Thursday that said religious groups didn't have to abide by the administration's rules, but the proposed bill would put Congress on the record in support of it.)
A memo issued by Ms. Murray noted that the 13,000 employees of Hobby Lobby took a job at an arts and crafts store, not a church or synagogue.
"The Supreme Court's decision allows for-profit business like Hobby Lobby to impose their religious beliefs on their employees," the memo says. "The Court decision ignores the fact that the employees' beliefs about religion are just as important and deserving of protection as the employers'."
It would be surprising if the bill picked up more than two or three Republican votes since it praises the Affordable Care Act, which is officially loathed by the Republican Party. It's a message bill, in the cynical parlance of Capitol Hill, which will die by filibuster in the Senate and has no chance of reaching the floor of the House. But at least that message is clear, and next week senators will have to reveal whether they think employers should have the right to intrude on their employees' lives.
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March 23, 2017 Thursday
Late Edition - Final
Republicans Face Dilemma on Health Bill
BYLINE: By JENNIFER STEINHAUER; Robert Pear and Thomas Kaplan contributed reporting.
SECTION: Section A; Column 0; National Desk; NEWS ANALYSIS; Pg. 1
LENGTH: 1332 words
WASHINGTON -- For the House Republicans who have never served under a Republican president -- roughly two-thirds of them -- the vote scheduled for Thursday on a measure to replace President Barack Obama's health care law is a legislative fantasia, the culmination of seven years of campaign promises impeded by Mr. Obama's veto pen.
But weeks of back-room machinations to bring a disparate group of lawmakers on board have left many Republicans with an excruciating choice: Pass a bill with an extremely limited constituency that could well wreak havoc with their own voters, and with Republicans' re-election prospects, or vote it down, undermining President Trump's agenda.
Speaker Paul D. Ryan said Wednesday that he was confident the House would pass the bill. But as of late Wednesday, roughly 30 Republicans had said they either would vote against the measure or had not made up their minds. That left the bill's sponsors short of the 216 votes needed, and on Wednesday night Mr. Ryan scheduled a meeting in the Capitol to try to win over skeptics.
If House Republicans reject the measure, the working relationship between the White House and Republican leaders in Congress, still in its infancy, will suffer a powerful blow. In Washington, failure often begets more failure, as opposition forces strengthen, alliances fragment and the thin foam of bipartisanship evaporates.
''How do we have any momentum to do anything else?'' asked Representative Richard Hudson, Republican of North Carolina. ''Without this bill, I don't know how you do tax reform,'' he said. If the bill fails, ''it's going to have negative repercussions for all of us.''
Mr. Trump, a man who rushes to hang his name in gold anywhere he can, has rejected the nickname that some have given the House bill: Trumpcare.
But he has begun a last-minute campaign to both sweet talk and vaguely threaten fellow Republicans into supporting the leadership's hastily written bill, though the measure, which would replace the Affordable Care Act's health insurance mandate and generous subsidies with tax credits to buy insurance, has been criticized by the right and the left.
Mr. Trump met with a group of the most conservative House members at the White House on Wednesday, and Republican leaders are depending on him to finish the job. Indeed, this week many Republicans have begun to acquiesce to his and the House leadership's desires, accepting that the bill, however flawed, is the best they are going to get.
At least for now, though, too many have not.
''The bill maintains Obamacare's overall structure and approach, an approach that cements the federal government's role in health insurance,'' said Representative Rick Crawford, Republican of Arkansas, an opponent of the bill who represents the concerns of the conservatives.
Other more moderate members expressed opposite objections. ''Under the current proposal, many South Jersey residents would be left with financial hardship or without the coverage they now receive,'' said Representative Frank A. LoBiondo, Republican of New Jersey. ''Our seniors on Medicare already struggle to make each dollar stretch.''
Some Republican leaders and those charged with drumming up votes suspect that some of the more conservative members are simply trying to force Mr. Ryan to cancel a vote on the bill so they do not have to go on record against Mr. Trump. But moderates may feel the pressure of voters: Large protests against the bill are planned for Thursday.
Further hampering them, House Republicans failed to do the grueling work of building a coalition outside Washington as Democrats did with the Affordable Care Act in 2009. While anti-abortion groups have warmly embraced the bill, which could restrict coverage of the procedure, it lacks other advocates. Doctors, nurses and hospitals have come out strongly against the measure, and insurance companies have been largely skeptical.
Even if Mr. Ryan manages to secure the bare minimum of votes required, the bill that would pass the House would not become law. The Senate expects to make significant changes in the legislation, dragging out the process deep into the spring, if it can pass any version at all.
Senate Republicans, largely those from states that chose to expand their Medicaid programs under the Affordable Care Act, so far have not seemed susceptible to pressure from leaders and Mr. Trump, listening instead to governors and constituents concerned about significant reductions in benefits.
Part of the bill's problem is time itself. Much has changed in the years since the Affordable Care Act passed, with millions of Americans, many in red states, now getting health insurance as a result of the law, as well as treatment for the prescription drug addictions that have plagued scores of communities.
''My goal for this whole process was to help the people the law harmed and not harm the people it helps,'' said Representative Dan Donovan, Republican of New York. At the same time, a fair number of conservatives would like to see those benefits greatly reduced, the central tension of the Republican debate.
As a result, it remains difficult to imagine a bill that could find its way out of the Capitol to Mr. Trump's desk, given the broad disparities in what Republicans now seek.
Even if they can come together, House Republicans risk making the same mistakes Democrats made in the beginning of Mr. Obama's term, when they pushed through what came to be known as Obamacare. That achievement, monumental at the time, ended up dragging down a once formidable Democratic majority and reducing the ability of Democrats to pass more legislation during his presidency.
Yet if the bill fails, Republicans in the House could end up like House Democrats under President Bill Clinton, who passed a controversial energy tax that was reduced to rubble in the Senate, but remained an albatross for Democrats in the 1994 elections.
The Democratic majority repeated that error in the early years of the Obama administration when the House passed a highly unpopular bill to cap the carbon emissions that cause climate change, only to see it go nowhere in the Senate, bringing down some House Democrats in the process.
Republican leaders are privately telling members that they do not want to be tarred as Republicans who voted with Democrats to maintain the Affordable Care Act. It's a message they expect to resonate once the bill reaches the Senate.
''We remain committed to the repeal and replacement of Obamacare with policies that actually work,'' Senator Mitch McConnell of Kentucky, the Republican leader, said on the Senate floor Wednesday as he urged members to get on board. ''Americans are ready for a better way forward after the failure of Obamacare.''
But the flaw in that theory is that plenty of groups that usually support Republicans have already expressed distaste for the repeal-and-replace measure and are urging members to reject it.
''In 2018, members are going to have to campaign for re-election and say, 'Look we repealed Obamacare,' and voters are going to look at their premiums and say, 'Oh no you didn't,' '' said Dan Holler, a spokesman for Heritage Action for America, a conservative group. ''In the long term, it is not in the best interest of the Republican Party to pass this bill.''
House Republicans could console themselves in thinking that the vote on Thursday could be more like the excruciating vote in 2003 for President George W. Bush's Medicare prescription drug benefit.
Then, House Republican leaders had to keep the vote open for hours as they twisted arms, finally securing passage, 216-215, over the opposition of the party's most conservative members, including the current vice president, Mike Pence, an Indiana congressman at the time.
But that measure, which did become law, has proved popular and durable, and the vote -- which led to ethics charges against some of the arm-twisters -- has largely receded into the history books.
URL: http://www.nytimes.com/2017/03/22/us/health-care-bill-republicans.html
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GRAPHIC: PHOTO: Tom Price, the secretary of health and human services, speaking last week at a news conference about the Republican bill to repeal and replace President Barack Obama's health care law. (PHOTOGRAPH BY GABRIELLA DEMCZUK FOR THE NEW YORK TIMES) (A13)
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November 20, 2013 Wednesday
Late Edition - Final
Navigating a Transformed Insurance Marketplace
BYLINE: By NANCY MARSHALL-GENZER.
Nancy Marshall-Genzer is a senior reporter in the Washington bureau of the public radio program ''Marketplace.''
SECTION: Section F; Column 0; Your Money; Pg. 7
LENGTH: 1039 words
ESSENTIAL benefits. Flexible benefits. High deductibles. Coinsurance. Bronze, silver, gold, platinum.
Welcome to what may be the most confusing year in the recent history of health care.
The Affordable Care Act is here and shaking things up. There are dashed expectations and plenty of uncertainty. But one thing is sure: Whether you're insured at work, as most employed Americans are, or are buying a policy on the exchanges, you're likely to be bearing more of the cost of your own care. And that means consumers need to know more and be smarter as they choose a health insurance plan.
Amber Hill, 26, knows what that feels like. She's shopping for health insurance for the first time, joining the millions of Americans buying coverage on the health care exchanges. She spent a lot of time in front of the computer in her Baltimore apartment, searching the Maryland insurance exchange for just the right plan. It was a lot of work.
''It's kind of a double-edged sword,'' she said, sighing. ''I know now that I have a lot more control over my health care, but at the same time that means I have to be proactive. I have to figure out what my needs are and I have to figure out what's the best way for me to meet those needs.''
And Ms. Hill has a lot of health care needs. When she was 17, she was found to have hydrocephalus, or ''water on the brain.'' She may need surgery at some point to drain the excess fluid. She has regular doctor visits, and doesn't want a huge co-payment. So she settled on a platinum plan with no co-payment for primary care visits, which will cost $217 a month after a monthly subsidy that is credited in advance is factored in. Ms. Hill is a student and part-time nanny, making around $22,000 a year; she had to wait until her next paycheck to afford the first premium.
But Ms. Hill's plan wouldn't work for everyone. The Affordable Care Act's online marketplaces, or exchanges, offer four main categories of coverage: bronze, silver, gold and platinum. Bronze plans pay 60 percent of the cost of health services deemed essential under the health care law, excluding premiums; platinum plans pay 90 percent.
Here are some tips on choosing the right coverage at the best price, whether you're shopping on the health care exchanges or getting coverage through your employer:
â- Consider a high-deductible plan. This may be the way to go if you're young and healthy. You have a lower monthly premium, but a higher deductible (the out-of-pocket expenses you must pay before coverage begins). High-deductible plans could also work if your insurance was canceled because it didn't meet Affordable Care Act requirements, which means it may have offered bare-bones coverage. Jon Katz, a Virginia insurance broker, tells his clients, ''Don't be afraid of the high-deductible option.'' He recommends pairing high-deductible plans with a health savings account: tax-free money you can use for health expenses.
â- Calculate your risks. If you have accident-prone children, a high-deductible plan may not be for you. Sarah Schut of Kent County, Md., is in her mid-40s, with five children. Her husband is self-employed, and she's about to leave her job to start a financial planning business. She's looking for just the right amount of coverage. ''I'd go for middle of the road,'' she said. ''I don't think I'm going to go for the Cadillac plan.''
She is leaning toward a silver plan, which covers 70 percent of expenses under the new law's formula. Ms. Schut said she had no problems with co-pays and deductibles, as long as illnesses or accidents were covered.
â- Factor in the free services. The Affordable Care Act requires most plans to provide coverage without additional charge to the policyholder for preventive services like physicals and immunizations. The preventive services could save the typical family of four several hundred dollars, said Bonnie Braun, a family economist at the University of Maryland.
You may want to factor that in if you plan to put money into a flexible spending arrangement. Such accounts run by employers let you set aside pretax money for medical costs. But if you don't spend the full amount by the end of the tax year, you lose it. ''So the answer could very well be -- especially this year for the first time -- that you would not want to set aside as much as you had before,'' Ms. Braun explained. You will have a safety valve in 2014, though. For the first time, you'll be able to carry over up to $500 to the next year.
â- Work the system. Some employers give premium discounts to workers who quit smoking, exercise or answer questionnaires about their health. The Affordable Care Act increases the discount. Suzanne Cleary, 38, a paralegal in Lanham, Md., already saves $144 a year filling out a questionnaire for Kaiser. She said the questions were easy: ''How many days a week do you work out? I think it asked you if you snore.''
â- Hope for the best, plan for the worst. Make sure you have money set aside for emergencies. If you have a deductible of $5,000 to $10,000, you'd better have that much money in your rainy day fund, ideally on top of the reserve of at least three months' expenses recommended by financial advisers. Ms. Cleary finds it difficult to plan. She pays around $500 per month to insure her family of four. But she never knows what to expect when a family member goes to the emergency room, or needs an operation.
''There's all this mystery behind how the providers are billing,'' she said, riffling through a folder of medical statements. ''It's not like you can go to the grocery store and you can look at three different types of cereal and know that one is $3.99, one is $4.99 and one is $1.99. You just don't know how much you're going to be paying for something, and you don't know if you're going to need anything.''
Brokers can help. If you're really lost, talk to an insurance broker like Jon Katz. You don't pay the broker, at least not directly. The insurance company you sign up with does. Mr. Katz has been working 18-hour days since Oct. 1. Phone calls to his office have doubled. He now gets 45 to 50 calls a day, mostly from people who buy their own insurance and are trying to figure out the most economical way to get the coverage they need.
URL: http://www.nytimes.com/2013/11/20/your-money/navigating-a-transformed-insurance-marketplace.html
LOAD-DATE: November 20, 2013
LANGUAGE: ENGLISH
GRAPHIC: PHOTO: SIGNING UP: Amber Hill in her Baltimore apartment, navigating the Maryland insurance exchange. She opted for a platinum plan that costs $217 a month. (PHOTOGRAPH BY MATT ROTH FOR THE NEW YORK TIMES)
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April 25, 2014 Friday
How to Get Better Insurance Data, Without Encouraging Conspiracy Theories
BYLINE: TERESA TRITCH
SECTION: OPINION
LENGTH: 720 words
HIGHLIGHT: The lack of a detailed monthly tally of the uninsured is a big hole in the nation’s statistics.
It has been a week since opponents of health-care reform accused the Obama administration of conspiring with the Census Bureau to undercount the number of uninsured Americans in an attempt to make the Affordable Care Act look more successful than it really is.
It was one of the wackier attacks on the A.C.A. And yet it has gained some traction, of sorts. No one in his or her right mind is endorsing the conspiracy theory. But in the aftermath of the accusations, a handful of senators are calling on the bureau to modify its survey method.
That would be fine, if they were advocating for true advancements in the bureau's already impressive statistics-gathering. Unfortunately, they seem more intent on satisfying the conspiracy theorists than in getting the best data possible.
Some background: At the center of the conspiracy theory are changes in the way the bureau asks people about their insurance coverage on the Current Population Survey, a monthly survey of some 50,000 people. The changes, in the works for more than a decade, are intended to elicit more accurate responses. The old questionnaire, for example, asked people if they had been insured in the prior year; the new one is more specific.
An unavoidable consequence of the change is a "break in trend," which will make it impossible to compare the results from 2013 and 2014 with earlier years. To the conspiracy theorists, this break is evidence of a dastardly attempt to manipulate the insurance picture.
What the senators want the bureau to do is keep asking the insurance coverage question the old, flawed way to preserve comparability, in addition to asking it the new way.
That would be both undesirable and unnecessary.
Undesirable, because asking basically the same question two different ways will yield conflicting data. Sure, one set of data would be intended only for purposes of comparison, while the newer set would reflect the best available tally of the number of uninsured. But conflicting numbers are bound to confuse the public.
Unnecessary, because comparative data on insurance coverage is available without having to continue asking a flawed question.
If the senators did their homework before reacting, they would know that for the past six years, the bureau has also asked about insurance coverage in the far larger American Community Survey.* The A.C.S. insurance-coverage question, which resembles the more accurate design of the new C.P.S. questionnaire, is currently used to get an annual fix on the number of uninsured people. Because the data goes back six years, it gives a consistent picture of the uninsured population before and after the enactment of the Affordable Care Act.
Instead of messing with the C.P.S., the senators should turn their attention to using the A.C.S. data more effectively. Because of its large sample size, the A.C.S. could be used to create an accurate monthly (as opposed to annual) tracking number of the uninsured, akin to what the bureau currently produces to help track unemployment and housing starts.
The lack of a detailed monthly tally of the uninsured is a big hole in the nation's statistics. Health care is one of the largest sectors of the economy and covering the uninsured is arguably the most important public policy related to it. Given that size and importance, it is not enough to broadly measure trends and progress, or lack thereof, once a year.
To turn the A.C.S. data from an annual to a monthly figure would not cost much, because the data is already being collected. A one-time appropriation, surely a rounding error in the budget, would be needed to re-purpose the existing data and to create the reporting protocol. Small annual appropriations would keep the monthly reports on track after that.
Working with the bureau to deliver monthly, comparable health coverage statistics would be a better use of lawmakers' time than pandering, even inadvertently, to conspiracy theorists.
*The percentage of the population without health insurance, according to the American Community Survey, 1-year estimates:
2008: 14.6
2009: 15.1
2010: 15.5
2011: 15.1
2012: 14.8
The Birth of a Conspiracy Theory
More 'Pinocchios' for the Koch Brothers, Please
Facts & Figures: A Cheaper 'Obamacare'
Kathleen Sebelius Was Too Cool and Too Patient
No Comment Necessary: Replacing the A.C.A. With...the A.C.A.?
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March 1, 2017 Wednesday
The New York Times on the Web
Democratic Response to Trump's Speech: Video and Transcript
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Former Gov. Steve Beshear of Kentucky, a senior Democrat best known for putting the Affordable Care Act into effect in a deeply conservative state, offered the Democratic response to President Trump's first address to a joint session of Congress on Tuesday. The following is a transcript, as prepared by the Federal News Service.
Reporters from The New York Times fact checked the Democrats' response.
BESHEAR: I'm Steve Beshear. I was governor of Kentucky from 2007 to 2015. Now I'm a private citizen.
I'm here in Lexington, Ky. -- some 400 miles from Washington -- at a diner with some neighbors -- Democrats and Republicans -- where we just watched the president's address. I'm a proud Democrat, but first and foremost, I'm a proud Republican, and Democrat, and mostly American. And like many of you, I am worried about the future of this nation.
Look, I grew up in Kentucky in a small town called Dawson Springs. My dad and granddad were Baptist preachers. My family owned a funeral home. And my wife, Jane, and I have been married for almost 50 years. I became governor at the start of the global recession, and after eight years, we left things a lot better than we found them.
By being fiscally responsible -- I even cut my own pay -- we balanced our budget and turned deficits into surpluses without raising taxes. We cut our unemployment rate in half. We made huge gains in high school graduation rates. And we found health coverage for over half a million Kentuckians.
We did that through trust and mutual respect. I listened. And I built partnerships with business leaders and with Republicans in our legislature. We put people first and politics second.
The America I love allowed a small-town preacher's kid to be elected governor, and it taught me to embrace people who are different from me, not vilify them. The America I love has always been about looking forward, not backward, about working together to find solutions, regardless of party, instead of allowing our differences to divide us and hold us back.
And we Democrats are committed to creating the opportunity for every American to succeed by growing our economy with good-paying jobs, educating and training our people to fill those jobs, giving our businesses the freedom to innovate, keeping our country safe, and providing health care that families can afford and rely on.
Mr. President, as a candidate, you promised to be a champion for families struggling to make ends meet, and I hope you live up to that promise. But one of your very first executive orders makes it harder for those families to even afford a mortgage. Then you started rolling back rules that provide oversight of the financial industry and safeguard us against another national economic meltdown. And you picked a cabinet of billionaires and Wall Street insiders who want to eviscerate the protections that most Americans count on and that help level the playing field.
That's not being our champion. That's being Wall Street's champion.
And even more troubling, you and your Republican allies in Congress seem determined to rip affordable health insurance away from millions of Americans who most need it. Does the Affordable Care Act need some repairs? Sure, it does. But so far, every Republican idea to ''replace'' the Affordable Care Act would reduce the number of Americans covered, despite your promises to the contrary. [Fact check: This is basically true.]
Mr. President, folks here in Kentucky expect you to keep your word. Because this isn't a game. It's life and death for people.
These ideas promise ''access'' to care but deny the importance of making care affordable and effective. They would charge families more for fewer benefits and put the insurance companies back in control. Behind these ideas is the belief that folks at the lower end of the economic ladder just don't deserve health care, that it's somehow their fault that their employer doesn't offer insurance or that they can't afford to buy expensive health plans.
But just who are these 22 million Americans, including 500,000 people right here in Kentucky, who now have health care that didn't have it before? Look, they're not aliens from some distant planet. They're our friends and our neighbors. [Fact check: Slightly high estimate.]
We sit in the bleachers with them on Friday night. We worship in the pews with them on Sunday morning. They're farmers, restaurant workers, part-time teachers, nurses' aides, construction workers and entrepreneurs working at high-tech start-ups. And before the Affordable Care Act, they woke up every morning and went to work, just hoping and praying they wouldn't get sick, because they knew that they were just one bad diagnosis away from bankruptcy.
You know, in 2010, this country made a commitment, that every American deserved health care they could afford and rely on. And we Democrats are going to do everything in our power to keep President Trump and the Republican Congress from reneging on that commitment. But we're going to need your help by speaking out.
Another commitment now being tested is to our national security. Look, make no mistake, I'm a military veteran myself, and I know that protecting America is a president's highest duty. Yet President Trump is ignoring serious threats to our national security from Russia, who's not our friend, while alienating our allies, who've fought with us side by side and are our friends in a dangerous world. His approach makes us less safe and should worry every freedom-loving American.
Instead, President Trump has all but declared war on refugees and immigrants. Look, the president can and should enforce our immigration laws. But we can protect America without abandoning our principles and our moral obligation to help those fleeing war and terror, without tearing families apart, and without needlessly jeopardizing our military men and women fighting overseas. [Fact check: False, unless the laws change.]
You know, another Republican president, Ronald Reagan, once said, ''In America, our origins matter less than our destination, and that is what democracy is all about.'' President Trump also needs to understand that people may disagree with him from time to time, but that doesn't make them his enemies. When the president attacks the loyalty and credibility of our intelligence agencies, the court system, the military, the free press, individual Americans, simply because he doesn't like what they say, he is eroding our democracy. And that's reckless. [Fact check: Few have been spared.]
Real leaders don't spread derision and division. Real leaders strengthen, they unify, they partner, and they offer real solutions instead of ultimatums and blame.
Look, I may be old-fashioned, but I still believe that dignity, compassion, honesty and accountability are basic American values. And as a Democrat, I believe that if you work hard, you deserve the opportunity to realize the American dream, regardless of whether you're a coal miner in Kentucky, a teacher in Rhode Island, an autoworker in Detroit or a software engineer in San Antonio.
Our political system is broken. It's broken because too many of our leaders think it's all about them. They need to remember that they work for us and helping us is their work.
Kentucky made real progress while I was governor because we were motivated by one thing: helping families. Democrats are trying to bring that same focus back to Washington, D.C. Americans are a diverse people. And we may disagree on a lot of things, but we've always come together when we remember that we are one nation, under God, indivisible, with liberty and justice for all.
Thank you.
URL: http://www.nytimes.com/2017/02/28/us/politics/democratic-response-video-transcript.html
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March 30, 2012 Friday
The Supreme Court and the National Conversation on Health Care Reform
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1357 words
HIGHLIGHT: Many Americans seem to feel they have a right to all the health care they need but should not be required to make provisions beforehand to pay for it, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
Once again America is having one of its "national conversations" on health care reform. This time the buzz is over arguments before the Supreme Court on the constitutionality of certain provisions in the Affordable Care Act. The justices' rulings will be landmark decisions, because they will indirectly go much beyond the act itself to our entire system of governance.
A fine synopsis of the issues now before the court is provided in a report by the Henry J. Kaiser Family Foundation. The following decision tree illustrates the logical sequence of decisions.
The two major substantive decisions the Supreme Court has to make are:
1. Whether Congress has the constitutional authority to mandate every legal resident in the United States to have insurance coverage for a specified package of health benefits (hereafter the "mandate") or whether that is an issue for the states to decide.
2. Whether Congress has the constitutional authority to expand eligibility for Medicaid benefits from the highly varied income thresholds that currently define eligibility to anyone under 133 percent of the federal poverty level (hereafter the "Medicaid expansion").
Severability: If the court ruled that either the Medicaid expansion or the mandate, or both, were unconstitutional, it would then have to decide, for each provision, whether striking it down invalidated the entire Affordable Care Act or whether only the stricken provision was invalidated.
The legal jargon for this issue is "severability." To avoid having entire laws invalidated over one provision that may be found unconstitutional by the court, legislation typically includes an explicit severability clause. For either strategic reasons or inadvertently, such a clause was not included in the Affordable Care Act.
The Supreme Court devoted a session of argument on Wednesday to this issue, and the questioning by the justices suggested a range of opinions on the issue, so what the future of the entire law may be is uncertain.
The Anti-Injunction Act: To rule on the mandate, the court will first decide whether the Anti-Injunction Act of 1867 applies to the mandate. The crucial issue here is whether the penalty exacted from individuals who choose not to obey the mandate to be insured is to be construed as a mere penalty or a genuine tax.
If the latter, under the Anti-Injunction Act the court should hear the case and rule on it only after someone has actually been forced to pay the penalty for violating the mandate, which could occur only in 2015 or thereafter.
The consensus among legal experts appears to be that the court will not feel bound by the Anti-Injunction Act and will rule on the mandate this year, most likely by the end of June.
The Mandate: I have discussed the mandate in several earlier posts, including this one. As explained there, a mandate on individuals to be insured is an actuarially necessary complement to two strictures on private insurers that seem to be popular with the public:
1. "Community-rated" premiums, that is, premiums divorced from the health status of any particular applicant for insurance and charged to all applicants for an insurer's coverage
2. "Guaranteed issue," that is, the requirement that an insurer must sell an insurance policy to any applicant willing to pay that insurer's community-rated premium for that policy.
For decades, Americans have lamented in vignettes published by various news organizations the families, stricken with serious illness, who find themselves unable to procure health insurance at premiums they can afford or are refused coverage altogether.
The Affordable Care Act was written to solve this problem by subjecting private health insurers to community rating and guaranteed issue.
But if Americans want the benefits of these two strictures, they must also be willing to countenance the mandate to be insured. It is not legislative hegemony. It is an actuarial necessity.
As I had noted in a post, that insight was shared during the 1990s by many Republican policy analysts and policy makers, including Senator Orrin Hatch of Utah, who now views the mandate as a violation of individuals' freedom. Republican legislators then openly countenanced the mandate and embodied it in federal legislation they proposed.
One can also view being insured for at least catastrophic health care a civic responsibility, as is the case in most other industrialized nations, including freedom-loving Switzerland. For example, asked in an interview in Health Affairs in August 2010 how he could defend the mandate to be insured to Swiss citizens, Switzerland's former secretary of health, Dr. Thomas Zeltner, responded:
That's easy. We will not let people suffer and die when they need health care. The Swiss believe that in return, individuals owe it to society to make provision ahead of time for their health care when they fall seriously ill. At that point, they may not have enough money to pay for it. So we consider the health-insurance mandate to be a form of socially responsible civic conduct. In Switzerland, "individual freedom" does not mean that you should be free to live irresponsibly and freeload from others, as you would put it.
Part of American exceptionalism, which we feel sets us apart from other nations, seems to be that Americans believe they have a moral right to critically needed health care, whether or not they can pay for it, but also believe that they should be free not to make financial provision for that event beforehand.
If the Supreme Court strikes down the mandate as unconstitutional - as it very well might, judging from the sharp and skeptical questions asked by the justices in arguments on Tuesday - it could lead to one of two distinct pathways.
First, as the Obama administration asserts, community rating and guaranteed issue would then have to be stricken from the Affordable Care Act. We would be back to the vignettes of Americans complaining about private insurers doing their actuarially sound and defensible thing, which can, however, be so devastating on American families.
An alternative would be to let these two provisions stand and force the insurance industry to live with them. As I explained in an earlier post, it would lead to what actuaries call the "death spiral" of individually purchased insurance, with shrinking risk pools of ever-sicker individuals and, naturally, ever-mounting premiums.
One could lambast the insurance companies for these ever-rising premiums, of course, but informed observers know better: the culprit would be the absence of a mandate to be insured. New York and New Jersey, which imposed community rating and guaranteed issue without a mandate to be insured, are living proof of that assertion. Risk pools there have shrunk and community-rated premiums have skyrocketed.
The Medicaid Expansion: As is shown in the chart above, the Anti-Injunction Act does not affect the court's jurisdiction over the Medicaid expansion. If I had to bet, the court will rule this provision constitutional. After all, a state does not have to take part in Medicaid, which is heavily subsidized with federal money. The program is voluntary.
For the expansion, the federal government would pick up 100 percent of the cost in the first three years, which descends over time to 90 percent thereafter. For the existing enrollment, the federal government traditionally has picked up 50 to 80 percent of the program's cost.
The opponents of the expansion appear to hold that for the federal government to make all of its generous Medicaid subsidies to a state conditional on that state's agreement to expand Medicaid eligibility to 133 percent of the federal poverty level is so powerful a fiscal incentive as to be coercive and hence unconstitutional, even though participation in Medicaid is voluntary. It strikes me as a stretch.
Health Care: Solidarity vs. Rugged Individualism
Awaiting the Supreme Court's Health Care Ruling
Reaction to the Final Hearing on the Health Law
The Supreme Court and Health Care
The Leading Liberal Against Affirmative Action
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January 1, 2014 Wednesday
Shorter Workweeks Are Likely in New Year
BYLINE: CASEY B. MULLIGAN
SECTION: BUSINESS; economy
LENGTH: 519 words
HIGHLIGHT: More employees are likely to be working shorter workweeks in 2014, as government policies nudge them and employers in that direction, an economist writes.
Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."
Three economic forces are pushing toward shorter workweeks for employees during the new year.
The red line in the chart below is a monthly index of the employment-to-population ratio, normalized to a value of 100 in December 2007, when the recession began. In this series, each employed person counts the same, regardless of how many hours she or he works.
By that measure, there has been hardly any labor market recovery because, as indicated by an index value of 93, employment per capita still remains 7 percent below what it was before the recession began.
Average weekly hours of private-sector employees (the blue line) returned comparatively quickly to near their prerecession level and have maintained that level over the last two years.
I predict that average weekly work hours will decline again over the next year because fiscal policy is now switching from penalizing part-time work to rewarding it.
Since 2008, government benefits for the long-term unemployed have served as a penalty for part-time work, because unemployment benefits are largely - if not entirely - withheld when an unemployed person accepts a part-time position. Moreover, people moving to part-time work from either full-time work or unemployment will find that the move renders them eligible for fewer benefits the next time they are laid off from a job.
Many of the part-time-work penalties disappear this week when the federal government stops paying long-term unemployment benefits (short-term unemployment benefits will continue, and they embody some of the same incentives), although the penalties would reappear should Congress resurrect the program.
Full-time work has traditionally offered health and other benefits that part-time jobs rarely do, and those benefits have kept a number of workers in full-time positions. The Affordable Care Act aims to end that advantage, by giving workers opportunities to obtain insurance outside the workplace.
In addition, in some cases the new insurance opportunities can be so inexpensive compared with employer insurance that people stand to, paradoxically, have more disposable income from working part time than they do from working full time.
The third economic force is that in January 2015 the Affordable Care Act begins to penalize employers that do not offer affordable health insurance, except that part-time employees (working less than 30 hours or four days a week) are exempt for the purposes of determining the penalty. This is another reason that part-time work - especially positions with 29-hour weekly work schedules - would increase at the expense of full-time work, at least if the mandate goes ahead as planned.
All together, it looks like many of the jobs in the new year will involve less work.
The Tax Equation in the Health Care Law
Testing a Premise on the Health Care Law and Part-Time Work
The New Economics of Part-Time Employment
What Job-Sharing Brings
Changing Assistance for the Unemployed
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July 15, 2014 Tuesday
Late Edition - Final
Groups Under Health Act Are Said to Aid Millions
BYLINE: By ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 17
LENGTH: 808 words
WASHINGTON -- More than 4,400 consumer assistance programs created under the Affordable Care Act helped an estimated 10.6 million people explore their new health insurance options and apply for coverage during the initial six-month enrollment period, according to a new Kaiser Family Foundation survey.
But the programs that operated in states with their own online insurance marketplaces got more funding and helped more people than those in states on the federal exchange, the survey found. In the District of Columbia and 16 states that ran or were working toward running their own exchanges, the programs helped about twice as many people, relative to the uninsured population, as they did in 29 states served by the federal exchange.
Karen Pollitz, a senior fellow at the Kaiser Family Foundation, said she was surprised by the large number of assistance programs, which the survey estimated to employ more than 28,000 full-time-equivalent workers and volunteers. ''The size of this infrastructure was something I wouldn't have predicted when we began,'' she said.
These workers, known as assisters, navigators or certified application counselors, were always seen as crucial to the success of the complicated law. But by the time the first enrollment period started last October, it was clear that their impact would vary from state to state, with wide discrepancies in how much was being spent to hire and train them. Many operated in hostile political climates, with some states passing laws restricting what they could do.
Most of the states that did not create their own exchanges -- and where assistance groups had less funding -- are led by Republican governors or legislatures who strongly oppose the law. The survey found the top reason people sought help from the programs was confusion about the Affordable Care Act and the insurance plans available through the exchanges. Many also encountered technical problems or did not have Internet at home.
About three-quarters of the programs said that ''most'' or ''nearly all'' of their clients who considered buying private coverage needed help understanding basic insurance terms, like ''deductible'' or ''in-network service.'' And nearly two-thirds of programs said they spent between one and two hours, on average, helping each client. ''It's not like buying shoes or books online,'' Ms. Pollitz said. ''It's a lot more complicated, and I think people will continue to need this level of help for a while.''
Just how many will get it remains an open question, in part because funding for assistance groups during the next open enrollment period, from Nov. 15 through Feb. 15, has not been fully determined. The Obama administration announced last month that it would make available $60 million for the programs -- $7 million less than last year -- in states that use the federal exchange during the 2014-15 enrollment period.
Still, three-quarters of the programs that participated in the survey said they would ''very likely'' continue their work in the next enrollment period. Federally qualified health centers, which tended to help more people than other types of assistance organizations, have continuing funding through the federal Health Resources and Services Administration and are likely to keep up their work, the survey said.
The Congressional Budget Office has estimated that 13 million people may enroll in coverage through the exchanges in 2015, including many who will be renewing plans and others signing up for the first time. About eight million people signed up for private coverage through the exchanges during the first enrollment period, which ended March 31, and several million more enrolled in Medicaid under the law's expansion of the program.
The survey was conducted through an online questionnaire between April 24 and May 12. Of 4,445 programs that were asked by email to participate, 843 did so, making for a response rate of 19 percent. The margin of sampling error is plus or minus four percentage points for the full sample. Since some kinds of programs were more likely than others to respond, the data was weighted to reflect the distribution of programs by type and by which kind of exchange -- state, federal or partnership -- they were helping people navigate.
About four in 10 of the programs could not help everyone who approached them, the survey found, and 12 percent said the demand for help far exceeded their capacity to provide it. Nine out of 10 programs said clients had already returned to them with post-enrollment problems.
The task next time could be tougher for assistance groups, Kaiser's report noted, because the people who were most motivated to sign up already did. On the other hand, Ms. Pollitz said, ''if the website isn't broken for the first two months of open enrollment, that means they will be able to help a lot more people.''
URL: http://www.nytimes.com/2014/07/15/us/assisters-helped-10-6-million-with-coverage-under-aca.html
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November 28, 2015 Saturday
Late Edition - Final
Instability in Marketplaces Draws Concern on Both Sides of Health Law
BYLINE: By ROBERT PEAR and ABBY GOODNOUGH
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 1260 words
WASHINGTON -- The latest turmoil in health insurance marketplaces created by the Affordable Care Act has emboldened advocates on both sides of the political spectrum, providing ammunition to conservatives who want to shrink the federal role and liberals who want to expand it.
UnitedHealth Group rattled federal officials when it announced last week that it was losing money in the insurance exchanges, saw no reason to expect improvements in 2016 and might pull out in 2017. Those concerns followed the collapse of 12 of the 23 nonprofit insurance cooperatives created with federal loans under the health law.
In addition, insurance markets in many states are unstable. Premiums are volatile. Insurers say their new customers have been sicker than expected. And the law is as divisive as ever. In the latest poll by the Kaiser Family Foundation, people reporting unfavorable views of the law outnumbered those with favorable ones, 45 percent to 38 percent.
Conservatives take the trends as confirmation of their pessimistic forecasts, another reason to repeal as much of the Affordable Care Act as they can. Liberals, on the other hand, say the uneven performance of private insurers strengthens the case they made unsuccessfully in 2009-10 for a ''public option'' -- a government-run health plan that would compete with private insurers.
Whether the problems in the marketplaces are just temporary setbacks for the law, as the White House contends, or signs of fundamental problems, as Republicans say, is not clear.
The Obama administration has repeatedly cited one important statistic in efforts to show the success of the health care law: More than 17 million uninsured people have gained coverage since Congress adopted the law in 2010 with no Republican votes in favor. And the law has cost the government less than projected, in part because spending on most types of health care has grown more slowly than expected.
But Republicans say that UnitedHealth's concerns show that the health law is unsustainable. Arguments once made by Republicans as polemical debating points are now echoed by consumers who say they cannot afford to use insurance because of high out-of-pocket costs.
Sylvia Mathews Burwell, the secretary of health and human services, surprised supporters of the law last month when she predicted a small increase, to 10 million, in the number of people who would have marketplace coverage at the end of 2016. At the end of June, 9.9 million were enrolled.
The projection alarmed some insurers because it implied that they would not see an influx of healthy people, whose premiums could help defray the cost of care for sicker people in a well-balanced ''risk pool.''
In applying for rate increases in 2016, many insurers filed data showing that they had lost money on their exchange business in 2014. To stop the losses and control costs, many have increased premiums and deductibles and other out-of-pocket costs, while reducing the number of doctors and hospitals available to consumers through their provider networks.
Conservatives want to let consumers buy policies with fewer mandated benefits, on the theory that such coverage would be more affordable. Some lawmakers say that insurers should be allowed to sell cheaper ''copper'' plans alongside the bronze, silver, gold and platinum plans available in the marketplaces.
''Obamacare piled mandates on the insurance industry that drive up costs and force many people to buy insurance that is more than they want or can afford,'' said Senator John Barrasso, Republican of Wyoming. ''The only people who are consistently signing up are the ones who get subsidies from Washington.''
But liberals draw a different lesson from insurers' troubles.
''With the news that United Healthcare may drop coverage, it's further proof that we need to implement a public option,'' wrote Representative Jan Schakowsky, Democrat of Illinois, last week in a post on Twitter.
Harvey J. Rosenfield, the founder of Consumer Watchdog, an advocacy group based in California, suggested that ''maybe the government should step in and run the system as Medicare for all.''
''People are sticking their heads in the sand if they say there are not serious problems with the Affordable Care Act,'' Mr. Rosenfield said, adding: ''People who were previously uninsured are indisputably better off, but many people in the middle class are struggling. They are entitled to buy health insurance, but that is an empty promise if the number of doctors and hospitals in your network has shrunk and deductibles have soared.''
In Colorado, unhappiness with the law has added momentum to an effort to replace it with a government-run health care program that would largely cut private insurers out. The initiative qualified for the 2016 ballot this month after supporters submitted over 158,000 signatures.
State Senator Irene Aguilar, a Democrat, said frustration with rising premiums and deductibles had fueled disillusionment, as had the recent collapse of a nonprofit cooperative that was the most popular insurer on the Colorado exchange.
The new system would be expensive, raising $25 billion a year in revenue from a 6.67 percent payroll tax on employers and a 3.33 percent tax deducted from workers' paychecks.
''I like to say the ground has been tilled'' by the Affordable Care Act, Ms. Aguilar said. ''People have a better understanding now of the limitations of trying to do health coverage in the same way we've always done it.''
This month's Kaiser poll found that Democrats remained largely supportive of the health law. But some, like Mark Kaley, a small-business owner in Indianapolis, say they are increasingly angry at the private insurers selling plans through the exchanges.
Mr. Kaley said that he and his wife had ''incredibly expensive'' coverage from UnitedHealth this year, using the federal exchange even though they did not qualify for premium subsidies.
''Where is my premium payment going?'' Mr. Kaley asked. ''If it's providing more health care to people who didn't have it before, then I'm O.K. with it. But if it's going to a private insurance company who wants to pay larger dividends to its shareholders and salaries to its executives, I'm not happy.''
Referring to the health law, Mr. Kaley said: ''Are there upsides to this? Yes. Were people in some way sold an optimistic view that is not panning out? Yes. People are angry and frustrated with that. The kinds of coverage and care they hoped they would have are just not there.''
Thomas M. Harte, an insurance agent in Hampstead, N.H., and a former president of the National Association of Health Underwriters, said that New Hampshire residents had clearly benefited from the Affordable Care Act in some ways. In 2014, he said, insurance was available from only one carrier, Anthem. But now, he said, consumers also have several additional choices, including Harvard Pilgrim and the nonprofit cooperative insurance plans based in Maine and Massachusetts.
''Anthem is reducing its premiums,'' Mr. Harte said. ''Other plans are fighting for market share.''
On the other hand, Mr. Harte said: ''Employers are outraged about the burden of having to report to the Internal Revenue Service on the insurance coverage they provide to each of their employees. The amount of effort they spend to comply with the reporting requirements of health care reform is truly unbelievable.''
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URL: http://www.nytimes.com/2015/11/28/us/politics/instability-in-marketplaces-draws-concern-on-both-sides-of-health-law.html
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(You're the Boss)
December 13, 2013 Friday
My Insurance Was Canceled - And That's O.K.
BYLINE: MELINDA F. EMERSON
SECTION: BUSINESS; smallbusiness
LENGTH: 724 words
HIGHLIGHT: Oddly enough, I also had trouble with the Independence Blue Cross website.
My journey to get a new health insurance policy is just about complete.
As I wrote in my previous post, I received a letter in October canceling my current individual health insurance policy effective Jan. 1. The first decision I had to make was whether to go to the individual marketplace or buy group coverage, as I used to, for my employees.
As it happens, most people on my staff get insurance through their spouse's employer, and my two single employees have individual insurance. While they expressed interest in group insurance, neither really wanted to take a cut in pay to cover their share of the costs. So I decided to determine how to get insurance for myself.
On the advice of my broker, I tried to apply at HealthCare.gov. But I had the same problems a lot of other people had, and I got nowhere fast. At the end of the process, I couldn't even tell if my application had been accepted.
I reached out to a health care advocate, Valerie Arkoosh, who is a senior policy adviser with the National Physicians Alliance, after hearing her speak at an event. When I asked if I should give up on the government's troubled website, she said I should keep trying, partly because the pricing could be better on the site than going through a broker or an individual insurer.
After waiting for the site to be upgraded in November, I decided to go back into the system at the beginning of December. My account had been updated and my application was submitted. As I expected, the site confirmed that I was not eligible for a subsidy. And yet, despite the progress, I still could not see any pricing information or details about the health plans available through the site.
And then I became ill with a sinus infection, which meant I needed to use my existing coverage one final time last week. My co-pay with my primary care physician was $30 (the plan charges $50 for specialists), and I paid $10 for a generic prescription at the local pharmacy. That was in addition to the $613.48, I have been paying each month for my current plan, which was canceled because it does not comply with the Affordable Care Act.
With the Dec. 15 deadline to secure health insurance looming - it has since been extended to Dec. 23 - I had no choice but to move forward. Even though I knew that the plans offered through the government exchange might be cheaper, I decided to check out what my current carrier, Independence Blue Cross, was offering.
Oddly enough, I had trouble with its website, too. So I called the help number, and a customer service representative transferred me to an insurance agent. After a couple of minutes, a pleasant women named Octavia got on the line. What happened next amazed me.
She asked if I qualified for a subsidy and warned that we could not move forward if I did - we would have to wait until the website was working. When I assured her that I did not qualify, she asked me what kind of coverage I wanted. I said Platinum P.P.O., which was the rough equivalent of the policy I had. She said that I would have $10 co-pays and $40 specialist co-pays. Then she asked my age, birth date, gender, address and whether I ever used tobacco. She asked if I was a current customer and for my policy number.
Two minutes later, she said my new policy amount would be - drum role, please - $443.59 a month. I was shocked and thrilled. It was a savings of $174.84 a month, which is substantial. Octavia said that a paper bill would be generated Dec. 8 and mailed to my house and that it would have to be paid before Jan 1. She gave me her phone number and encouraged me to call her if I had any problems.
While the introduction of the Affordable Care Act and its website was poorly executed, I am delighted that the law has eliminated pre-existing conditions and lowered rates - at least for me. My big question now is whether the law will keep my insurance company from raising my rates arbitrarily in the future. I'll keep you all posted.
Melinda F. Emerson is founder and chief executive of Quintessence Multimedia, a social media strategy and content development company. You can follow her on Twitter.
My Health Insurance Was Canceled
An Owner Figures Out How to Save on His Health Insurance
A Business Owner's First Brush With HealthCare.gov
A Small Business Starts to Navigate the Affordable Care Act
Small Business Health Exchanges Delayed Again
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(You're the Boss)
April 7, 2014 Monday
Ezekiel Emanuel Further Explains His Prediction That Employers Will Drop Health Insurance
SECTION: BUSINESS; smallbusiness
LENGTH: 1291 words
HIGHLIGHT: “Look,” said Dr. Emanuel, “we talked to a lot of business owners. We talked to lots of consultants who deal with businesses.”
Our recent interview with Dr. Ezekiel J. Emanuel about his provocative prediction that most employers will abandon health coverage by 2025 struck a nerve with You're The Boss readers.
It came as no surprise that Dr. Emanuel's claim, first made in his new book, "Reinventing American Health Care," would be swept up in the broader political and ideological debate about the Affordable Care Act. But in their many comments, readers raised interesting questions, and we took some of them back to Dr. Emanuel in another conversation that appears, edited and condensed, below.
It's worth noting that among those readers who identified themselves as small-business owners, there was little disagreement: Most expressed a strong desire to get out of the health insurance business. "I have provided health insurance for 30 years and am dropping it in 60 days," wrote J of New York. To his employees, he continued, health care costs are an abstraction, "and my contributions to it are not clearly recognized. Now they will be."
Q.
Your prediction provoked a good bit of anger directed both at employers and the Affordable Care Act. But it seems to me that the argument you're making is that if this happens, it's going to be because employees aren't looking to employers to offer insurance.
A.
Right. It's not because of anything in the law. It's about the dynamic between employers and employees. Employers react to the market. Actually, after the interview appeared a colleague of mine wrote me and said, "You know, my sister would love to be able to go into the exchange, because she can get a better deal for herself, but her employer's not going that direction, at least not now."
Q.
There's a lot of skepticism that the policies on the exchanges are as good as the policies that are available to groups, particularly to large groups.
A.
Yeah. The predicate, the assumption, behind my claim is that the exchanges are going to get better, that they're going to be desirable shopping places, the options are going to be highly desirable, there's going to be more choice for people. If the products available on the exchange are not equivalent to what responsible large private employers are doing, they're not going to send their workers there. It's just that simple.
Q.
What has to happen for exchange plans to be able to compete with group plans?
A.
I do think the exchanges can offer better products. The exchange is not just the website - it includes things like product development, working with the insurance company to get better product out there. But insurers aren't going to develop these plans unless they perceive there's a market there for them. And they're not going to perceive there's a market unless they can be sure that it's a nice shopping experience and that people really want those products on the exchange. So I think this is a chicken-and-egg problem.
Q.
Do 7.1 million enrollees help?
A.
Yeah. Especially since it was so unexpected. It says there's this huge pent-up demand out there for affordable health insurance. Despite not having two months at the start, getting it screwed up, people predicting the demise of health care reform, Americans signed up in droves.
Q.
One reader came back to us with a hypothetical: a $4,000 insurance benefit that an employer converts to a cash raise - but when you account for the taxes for the employee and the penalty for not offering insurance, that $4,000 now costs the company $7,800. What do you say to that math?
A.
Yeah, I think he's got another good point against me, and Mark Pauly, my colleague, has pointed out that there's a lot of value in employers providing the insurance, in just this way, that it's going to be hard to replace.
Q.
On top of that, a lot of people are skeptical that employers who drop coverage will actually compensate their employees with a raise.
A.
Yeah, I know, the American public is extremely skeptical of that. But every economic analysis that's been done of health insurance with employers and wages shows that it is replaced almost dollar for dollar. It's not replaced on Day One necessarily, but over a very short period of time, a few years, people get the money, in terms of higher wages. And similarly, one should say that when employers give you a richer health insurance package, that usually corresponds over time to a slower increase in wages.
Q.
Do you worry that this could become a mechanism for employers to offload the rising cost of health insurance?
A.
Yes, exactly, I worry about that. From what I can tell - and here I'm getting out of my comfort zone - what employers are worried about more than the actual increase (although they keep claiming it's the increase) is the unpredictability. Organizing their planning is harder when the costs each year are so unpredictable.
Q.
The other day, Robert Gibbs, a former Obama administration adviser, told an audience that the employer mandate would never be implemented - it would be killed off. What do you think of that?
A.
No way. He's wrong. Period.
Q.
If employers drop health insurance and send people to the exchanges, do you see that in any way as a step toward a single-payer system?
A.
No! There are some Americans that want single-payer. All I can say is the majority don't. Americans aren't into the single-payer game. It ain't happening. We barely got the Affordable Care Act through. We certainly would not have gotten a single-payer proposal through. Every responsible liberal group in 2009, 2010 said, look, the worst option is to do nothing. People understood very clearly that between doing nothing and reforming the system, it was important to reform the system.
Q.
The last time we spoke, you said that nobody in the administration thought through how the Affordable Care Act might affect businesses. Looking back now, should there have been someone in the White House who was really focused on this from the perspective of business owners?
A.
Look, we talked to a lot of business owners. We talked to lots of consultants who deal with businesses. I think I had like 70-some odd meetings with various groups. I took so many meetings, people thought I was crazy. The fact of the matter is that no one can have perfect clarity as to how things are going to unfold. Just take a simple example: If I had told you three months ago we're going to pass 7 million people signing up on the exchange, you would have taken that bet, and I would've looked like an idiot at that point. That's just three months ago. I'm making a prediction for 11 years from now, and almost 15 years after the passage of the Affordable Care. O.K.? Let's be humble, and let's be a little more reasonable about the accuracy of predictions.
Q.
How big a problem will it be if Hobby Lobby wins its Supreme Court case, and employers are able to carve out exemptions from the health law based on religious views?
A.
I think this opens a huge can of worms as to what anyone's religion is or what the religious dictates are, and how those connect with health services. There are lots of religions that don't believe in circumcision - we're not paying for circumcision. Or, we don't believe in premarital sex, so we're not going to cover the cervical cancer treatment, because the only way you get it is through premarital sex. My religion doesn't like smoking - all right, we're not paying for emphysema care or lung cancer care. Where is the end of this?
An Owner Asks a Question About Offering Employees a Stipend to Buy Health Coverage
Why Employers Will Stop Offering Health Insurance
The I.R.S.'s Final Mandate Reporting Rules? Still Complicated
Study Indicates That Bill Redefining Full-Time Employment Would Have Costs
Why Most Small-Business Owners Will See Premiums Rise Under A.C.A.
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The New York Times
November 16, 2016 Wednesday 00:00 EST
HealthCare.gov Sees Early Rise in Enrollment Amid Worries on Law's Future
BYLINE: ROBERT PEAR
SECTION: US; politics
LENGTH: 749 words
HIGHLIGHT: More than 300,000 people selected plans in the three days after the election of Donald J. Trump, who has called the Affordable Care Act a "disaster."
WASHINGTON - More than a million people have signed up for 2017 health insurance coverage on HealthCare.gov, and more than 300,000 of them selected plans in the three days after Donald J. Trump won the presidential election, the Obama administration said on Wednesday.
About one-fourth of those using the online exchange to sign up - 246,400 people - were new to the federal marketplace, and the other 761,800 were renewing coverage they had this year.
The data covered plan selections from Nov. 1, the first day of the fourth annual open enrollment period, to Nov. 12, for the 39 states that use the health care website. Federal officials said the total was 53,000 more than the number of selections in the first 12 days of the enrollment season last year.
Andrew M. Slavitt, the acting administrator of the federal Centers for Medicare and Medicaid Services, said he was pleased with the pace of plan selections. "It shows that health insurance is something people want and need," he said.
Christen Linke Young, the deputy director of the agency that runs the federal marketplace, said the Obama administration was "moving forward" with planning for 2018. "It is business as usual with respect to how we are talking" to insurers, she said.
In the presidential campaign, Mr. Trump said repeatedly that Congress must "completely repeal Obamacare," which he described as "an absolute disaster."
But in the last week, he indicated that he would like to preserve certain popular features of the law, including ones that guarantee access to insurance for people with pre-existing conditions and that allow young adults to stay on their parents' insurance until age 26.
Since Nov. 9, the day after Republicans secured control of the White House and both houses of Congress, the federal marketplace has received 8,000 telephone calls from people wanting to know how the election would affect their insurance coverage, Mr. Slavitt said.
He said the government had assured callers that "nothing is changing now and in the short term." Republicans and Democrats disagree over the law, but "nobody wants to do something disruptive to consumers," he said.
Mr. Slavitt's agency is responsible for health programs that account for about one-fourth of all federal spending, but he said he had not had any contact with Mr. Trump's transition team.
For the current open enrollment period, which runs through Jan. 31, the administration has declared a goal of having 13.8 million people sign up for coverage, an increase of 1.1 million over the last enrollment season.
Major insurers have pulled out of the marketplace in many parts of the country, and premiums for many of the remaining plans have shot up. But the Obama administration is trying to counter those trends with the message that federal subsidies will also increase, so that the consumer's share of the premium will not rise much, especially if consumers are willing to switch to less costly plans.
One reason for rate increases next year is that the federal government has not paid insurers as much as they were expecting to receive to help offset financial losses under the Affordable Care Act.
The United States Court of Federal Claims recently rejected a lawsuit filed by an Illinois insurer, the Land of Lincoln Mutual Health Insurance Company, a nonprofit cooperative that had sought damages for the government's failure. The ruling is ominous for insurers because many of them contend that they, too, were shortchanged, and a number have filed similar lawsuits.
At issue is a program intended to compensate insurers that lose substantial sums in the federal marketplace. Losses far exceeded expectations, and the Obama administration did not have enough money to make the promised "risk corridor" payments.
Judge Charles F. Lettow of the claims court said the government had neither a statutory nor a contractual obligation to pay the company more than it did - 12.6 percent of the amount Lincoln was expecting for 2014 and nothing for 2015.
The money was supposed to come from profitable insurers, but the government did not collect enough to pay the amounts owed to unprofitable insurers. The Affordable Care Act did not provide money to make up the difference, and "no valid contract exists" between the government and the Land of Lincoln insurance company, Judge Lettow said.
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Trump Floats an Olive Branch: Might Keep Parts of the Health Law
LOAD-DATE: November 30, 2016
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March 12, 2017 Sunday
Late Edition - Final
G.O.P. Advances Risky Strategy on Health Care
BYLINE: By ROBERT PEAR and THOMAS KAPLAN
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1624 words
WASHINGTON -- President Trump and House Republicans are pressing forward with a high-risk strategy to repeal and replace the Affordable Care Act, disregarding the views of medical professionals and potentially imperiling the party's political future in conservative states where many voters stand to lose their health care.
The effort could cause upheaval in an already roiled insurance market next year, as Republicans face voters for the first time with Mr. Trump in the White House -- though that turmoil would happen only if the plans manage to clear a divided Senate.
Mr. Trump is showing only a tenuous grasp of the legislative process and mercurial leadership in rounding up support. But Republicans who spent seven years promising to scrap President Barack Obama's signature domestic achievement say their strategy is worth the risk.
''If you ask someone to give up something, there will be resentment,'' said Representative Michael C. Burgess, Republican of Texas and chairman of the Energy and Commerce subcommittee on health. But, he added, ''If that claims my congressional career, so be it. It will be worth it to me to have effected this change.''
The risks mounted steadily throughout this past week. The insurance and health care industry cited likely damage to medical coverage for millions of Americans. Conservatives fought the bill on the grounds that it did too little to reduce subsidies. And House leaders moved forward even though the influential Congressional Budget Office has yet to assess the costs or effectiveness of the plan.
Ultimately, Republicans are counting on Democrats to step in and help repair what even Republicans anticipate as upheaval if a repeal measure is passed without a broad remake of American health care.
Republican leaders have made no effort to hide the strategy. House Speaker Paul D. Ryan spoke at length this past week about a three-stage effort: First, with only Republican votes, repeal major parts of the health law and put in place some new provisions. Second, let Health and Human Services Secretary Tom Price use regulatory powers to try to stabilize insurance markets. Third, pressure Democrats to help with a series of bills to complete the replacement and change the health care system more to the liking of conservatives.
But that bet carries enormous peril for consumers and insurers -- and congressional Republicans and the Trump administration.
Democrats, eyeing potential turmoil in the run-up to the 2018 midterm elections, have little political reason to cooperate. ''One thing is clear,'' said the House Democratic whip, Representative Steny Hoyer of Maryland. ''House Republicans are going to have to find the votes on their own to dismantle the protections incorporated in the Affordable Care Act that the American people now have.''
A growing chorus of Republican policy experts and senators are pleading to slow the process down or risk a political blood bath.
But Republican leaders and Mr. Trump appear to be laying the groundwork for blaming the law they are annulling for the fallout likely to come in the repeal's wake.
Mr. Trump asserted on Friday that 2017 would be ''a disaster'' for the health law. ''That's the year it was meant to explode, because Obama won't be here,'' he said, adding that ''as bad as it is now, it'll get even worse.'' On Saturday, he took to Twitter: ''ObamaCare is imploding and will only get worse. Republicans coming together to get job done!'' And Vice President Mike Pence traveled to Louisville, Ky., on Saturday to assure residents that ''the Obamacare nightmare is about to end.''
What is clear is that 2018 -- a year that Republicans say will be messy -- will loom large for them as they move toward a vote on the measure. But Republicans say that gives them nearly a year of time, since people will experience few changes with their health care in 2017.
Under the proposed House legislation, individuals would no longer be subject to a penalty if they go without health insurance, a politically popular change that would be retroactive to 2016. But they would still enjoy the protections of the Affordable Care Act: Insurers would have to offer a suite of essential health benefits, could not deny them coverage because of pre-existing conditions and could not impose annual or lifetime caps on coverage.
Insurers would be free to raise their premiums to meet these requirements, but because current policies are locked in for the year, voters would not see the effects until 2018. If young, healthy Americans flee the market, freed from the mandate, premiums could soar next year.
Insurers say this is a recipe for havoc. Eliminating the penalties used to enforce the mandate that most Americans have insurance ''would add to short-term instability in the market,'' said Marilyn B. Tavenner, the chief executive of America's Health Insurance Plans, a lobby for insurers.
Instead of the current tax penalty for failing to secure coverage, the bill would introduce a penalty for purchasing insurance after letting coverage lapse: To encourage people to maintain ''continuous coverage,'' insurers would impose a 30 percent surcharge on premiums for people without coverage for 63 days or more.
But that provision would not take effect until 2019 -- again leaving 2018 unprotected.
All of that has created immense uncertainty for insurers, which have until June 21 to notify the government if they intend to participate in the federal insurance marketplace next year.
''The current uncertainty makes it difficult to assess what our product offerings for 2018 might be,'' said Roy D. Vaughn, a senior vice president of BlueCross BlueShield of Tennessee, which has lost more than $400 million in the federal insurance exchange in the last three years. ''All options are on the table for 2018.''
For all those worries, the Republicans' repeal campaign did gain momentum this past week as two House committees approved the legislation, with the full House expected to take it up later this month. Mr. Trump praised the legislation, even as it was harshly criticized by doctors, hospitals, insurers and state officials, who said it could increase the number of uninsured and destabilize insurance markets. The Congressional Budget Office is expected to render its verdict on the legislation this coming week, with an estimate of the bill's costs and its effect on coverage. Republicans are bracing for bad news.
Deep Banerjee, who follows insurers for Standard & Poor's, estimated that the Republican plan would reduce enrollment in the individual market by two million to four million people and in the Medicaid market by four million to six million. Brookings Institution analysts predicted that the budget office would expect the bill to cause the number of uninsured to rise by at least 15 million.
''Republicans do not currently have the votes to pass their health care bill in the House,'' said Kim Monk, a health care analyst at Capital Alpha Partners, a policy research firm for investors. But she sees a 60 percent likelihood that they will clear that hurdle.
''Republicans campaigned on 'repeal and replace,''' said Ms. Monk, a former Senate aide. ''If they do not deliver, the Affordable Care Act will stay in place, and Republicans would pay a price in the next election.''
The bill may need to move to the right to get through the House, where a formidable bloc of conservatives wants more aggressive steps to rein in the growth of Medicaid. But to win approval in the Senate, the bill may have to move in the opposite direction -- to satisfy more moderate Republicans and those from states that have expanded Medicaid, like Ohio and Colorado. At the same time, three Republican senators -- Ted Cruz of Texas, Mike Lee of Utah and Rand Paul of Kentucky -- will be tugging the bill to the right.
The Senate majority leader, Mitch McConnell of Kentucky, is determined to secure repeal of the Affordable Care Act, which he has called ''the single worst piece of legislation that has been passed in the last half-century.''
But several provisions of the bill, including proposed cuts in Medicaid, face resistance from health care providers, especially hospitals, which are present in virtually every congressional district and plan an all-out lobbying campaign. In addition, Democrats are gaining some traction with their argument that the bill acts like Robin Hood in reverse, taking health insurance from the poor and giving tax breaks to the rich.
On the other hand, Mr. Trump has successfully defied conventional wisdom before. His Twitter-fueled ability to command a spotlight could be a formidable asset as Republican leaders try to collect votes for the health care bill.
For health policy experts, liberal and conservative, the rush to enact a measure that even its authors concede is incomplete is dangerous. On Friday, two conservative critics of the Affordable Care Act, Joseph Antos and James C. Capretta, urged Republicans to slow down and get their health legislation right.
''While the emphasis on moving quickly is not surprising, there is also a significant risk that unnecessary haste could lead to major mistakes in the legislation that would generate strong political backlash,'' wrote Mr. Antos and Mr. Capretta, scholars at the American Enterprise Institute. ''The A.C.A. has extended insurance coverage to millions of people with expensive health problems, and to many lower-income households. Acknowledging this is not the same thing as saying the A.C.A. should not be changed.''
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This is a more complete version of the story than the one that appeared in print.
URL: http://www.nytimes.com/2017/03/11/us/politics/republican-health-law-repeal-strategy.html
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November 11, 2016 Friday 00:00 EST
Trump Floats an Olive Branch: Might Keep Parts of the Health Law
BYLINE: CARL HULSE, JULIE HIRSCHFELD DAVIS, ALAN RAPPEPORT and MAGGIE HABERMAN
SECTION: US; politics
LENGTH: 1875 words
HIGHLIGHT: The president-elect said that, after talking with President Obama this week, he might be willing to leave in place two popular provisions of the Affordable Care Act.
President-elect Donald J. Trump overhauled his transition team from top to bottom on Friday, expanded his outreach to more establishment Republicans, and even offered an olive branch to President Obama - albeit a narrow one.
On the other side, Democrats signaled they would move left in the wake of Hillary Clinton's narrow-but-startling defeat, and the president-elect's legal antagonist, Gloria Allred, made it clear that neither she nor many of the women who have accused him of sexual assault are going anywhere.
Join us again on Monday for continuing live updates on the transition to the 45th presidency of the United States.
Trump: Maybe I'll keep parts of the Affordable Care Act.
Mr. Trump said Friday that, after talking with President Obama this week, he might be willing to leave in place parts of the Affordable Care Act once he's in office.
Mr. Trump made the comments to The Wall Street Journal in his first interview since winning the election. The newspaper said Mr. Obama had urged the president-elect to reconsider repealing his signature health care law, which Mr. Trump said had become "unworkable."
But in the interview, Mr. Trump said he told the president that he would consider keeping two provisions of the law: the prohibition against insurers denying coverage because of a patient's pre-existing condition; and the one that allows parents to keep their children on their insurance plans until they turn 26.
The problem: Without a mandate for everyone to buy health insurance, the popular pre-existing condition provision could send insurance companies into a tailspin, because their costs would rise with sicker customers, and that would not be offset by healthy consumers forced to buy insurance.
'A lovely call' from Clinton.
Mr. Trump said in an interview to be shown on "60 Minutes" Sunday that Mrs. Clinton "couldn't have been nicer" in a congratulatory call she made to concede the election, and that Bill Clinton had complimented him on "one of the most amazing" presidential runs he had ever seen.
"It was a lovely call, and it was a tough call for her - I mean, I can imagine, tougher for her than it would have been for me," Mr. Trump said. "She couldn't have been nicer. She just said, 'Congratulations, Donald, well done.'"
Mr. Trump, who on Thursday said he would seek Mr. Obama's counsel about the presidency, said he would consider asking for Mr. Clinton's as well.
Mr. Trump also promised that there would be no lapse in health insurance for millions of Americans covered under the Affordable Care Act when he repeals and replaces the law.
"We're going to do it simultaneously - it'll be just fine," Mr. Trump said. "That's what I do. I do a good job. You know, I mean, I know how to do this stuff. We're going to repeal it and replace it. And we're not going to have, like, a two-day period and we're not going to have a two-year period where there's nothing."
And speaking of olive branches - Mitt Romney
Mr. Trump has quietly reached out to Mitt Romney, the 2012 Republican nominee who took an impassioned stand against Mr. Trump during the campaign.
The call came after Mr. Trump's surprise victory on Tuesday night, according to two people briefed on it, although it was unclear how it went and what was said.
Aides to Mr. Trump and Mr. Romney did not respond to requests for comment.
Gloria Allred eyes the Paula Jones model.
With her eye on the right's Paula Jones legal crusade of the 1990s, Gloria Allred, the civil rights lawyer representing women who have accused Mr. Trump of sexual assault, is trying to lure the president-elect into a legal battle before he takes office.
Ms. Allred challenged Mr. Trump on Friday to retract his threat to sue his accusers for defaming him and suggested that she might bring a case against him if he refused. She also said that she was prepared to countersue if Mr. Trump made good on the threat.
"President-elect Trump now has the opportunity to act presidential," Ms. Allred said at a news conference with Summer Zervos, the former contestant on "The Apprentice" who said last month that Mr. Trump tried to seduce her and grabbed her breasts in 2007.
Ms. Allred cited a precedent for suing a sitting president: Ms. Jones.
"Obviously the lawsuit against President Clinton by Paula Jones did proceed while he was in office for actions that were alleged to take place prior to his becoming president," she said.
The Jones case forced Mr. Clinton into a deposition that resulted in his impeachment on charges of lying under oath about an affair with an intern.
A sobbing Ms. Zervos sat next to Ms. Allred and offered her own solution: "What happened to a good, old-fashioned I'm sorry?"
Mike Pence is in, Chris Christie is out.
Vice President-elect Mike Pence will take the lead on the president-elect's transition.
Gov. Chris Christie of New Jersey, who is under a cloud after two aides were convicted of conspiring to shut down traffic on the George Washington Bridge in the so-called Bridgegate scandal, moves aside.
Mr. Trump told advisers that he wanted Mr. Pence's Washington experience and contacts. An executive committee, which will include members of Congress, will advise Mr. Pence as the process moves forward.
See the full story.
Corey Lewandowski is out at CNN, and (unofficially) back in with Trump.
Corey Lewandowski, who was fired as Mr. Trump's campaign manager and then went to work for CNN, even as he continued to consult with the campaign, resigned Friday from his political commentator role, the network confirmed.
Mr. Lewandowski is expected to take a position in the Trump administration.
He was seen in Trump Tower on Wednesday immediately after Mr. Trump's victory, chatting with senior aides and attending meetings. Mr. Lewandowski did not return calls for comment.
Mr. Lewandowski was viewed as a controversial appointment by the network; he had signed a nondisclosure agreement with Mr. Trump that prevented him from criticizing the candidate publicly, and he was still being paid by the campaign while working for CNN.
Chuck Schumer backs Keith Ellison to head of the D.N.C.
Senator Chuck Schumer of New York, the incoming Democratic leader, threw his weight behind Representative Keith Ellison of Minnesota on Friday to be the new chairman of the Democratic National Committee, the clearest sign yet that, in defeat, the party will move to the left.
After losing the working-class Rust Belt to Mr. Trump, Democrats could have recruited an industrial-region populist like Representative Tim Ryan of Ohio, who represents the Youngstown area. But Senator Bernie Sanders of Vermont quickly backed Mr. Ellison, who is black, Muslim and an ardent progressive.
Two former governors, Howard Dean of Vermont and Martin O'Malley of Maryland, also expressed interest Friday in being the party's new committee chairman.
Million Woman March brewing
So much for a warm welcome to Washington.
Groups on social media are trying to coordinate a Million Woman March the day after Mr. Trump's inauguration in protest of the new president. The march will go from the Lincoln Memorial to the White House on Jan. 21 to show "strength, power and courage." Men are also encouraged to attend.
"No woman is free unless all women are free," the organizers of the march wrote on the Facebook page where it is being organized.
State groups for the march have already been formed for people to coordinate travel to the capital. However, some fear that the idea could become a logistical nightmare coming so close to Inauguration Day because of the lack of hotel rooms and the potential for clashes with Trump supporters
Where will Trump live?
Among the president-elect's most pressing questions as he prepares to take office is where he should live.
Mr. Trump, a provincial homebody who divides his time among golf courses in Florida and New Jersey and his townhouse apartment in Manhattan, is weighing how much time to spend in Washington, according to two people familiar with his deliberations.
One option is spending weekends in New York and most of the week in Washington. Mr. Trump's wife, Melania, is ultimately planning to move to Washington, according to one person briefed on the discussions, but their 10-year-old son, Barron, is still in school.
Trump's problems with women continue.
Mr. Trump may be triumphant, but Gloria Allred isn't done with him yet.
More than 10 women accused Mr. Trump of sexual assault after a video bragging about his groping habits emerged last month. Ms. Allred, the lawyer who has been working with many of the women, does not appear to be letting the president-elect off the hook.
At 2:30 p.m. Eastern time on Friday, she said that she was going to issue a challenge to Mr. Trump at a news conference with one of his accusers who has already come out publicly to tell her story. Ms. Allred would not reveal the name of the woman before the event or share any details of the challenge.
Before the election, Mr. Trump said that the accusers were all lying and that he might sue them. Ms. Allred told ABC News on Thursday that her clients had no plans to sue Mr. Trump at this point, but that they would countersue if he did so.
Harry Reid weighs in.
Senator Harry Reid of Nevada, the departing Democratic leader, added his voice to the postelection statements on the president-elect. Unlike most Democrats, he gave no quarter:
The election of Donald Trump has emboldened the forces of hate and bigotry in America.
White nationalists, Vladimir Putin and ISIS are celebrating Donald Trump's victory, while innocent, law-abiding Americans are wracked with fear - especially African-Americans, Hispanic Americans, Muslim Americans, L.G.B.T. Americans and Asian-Americans. Watching white nationalists celebrate while innocent Americans cry tears of fear does not feel like America.
Bernie Sanders to protesters: Chill.
Some of the anti-Trump protesters who have taken to the streets this week are supporters of Mr. Sanders, and on Friday the former Democratic presidential candidate reminded them that creating chaos and disorder should not be their goal.
Our job is to deal with the real issues - to deal with our rigged political and economic system - not take our anger out on our neighbors. - Bernie Sanders (@SenSanders) November 11, 2016
Security is beefed up around Fortress Trump.
Trump Tower, the skyscraper on Fifth Avenue and the home base of the president-elect, has become a fortress in the wake of the election.
The lobby, designated a public space by the City of New York, was closed off on Friday morning as Mr. Trump met with advisers. A large police presence surrounded the building.
The tower was built with a special permit more than 30 years ago. The city granted Mr. Trump extra space in exchange for maintaining public access to the lobby.
Peter Thiel joins the transition.
Peter Thiel, the Silicon Valley libertarian who secretly financed a lawsuit against the website Gawker, was named a member of the Presidential Transition Team Executive Committee on Friday afternoon.
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With Trump's Election, a Bonanza for Washington Lobbyists
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January 4, 2017 Wednesday 00:00 EST
Republicans Are Courting Disaster on Health Care;
Editorial
BYLINE: THE EDITORIAL BOARD
SECTION: OPINION
LENGTH: 809 words
HIGHLIGHT: After years of attacking Obamacare they still aren't ready to repeal it. They're about to do so anyway.
And so it begins. After six years of posturing and futile votes to repeal the Affordable Care Act, Republicans in the Senate have started a process to erase the most important provisions of the health reform law with a simple majority. Millions of Americans are at risk of losing their coverage.
Republican opponents of the health care law insist that it has failed, though it has reduced the number of uninsured Americans to the lowest level in history. They say that it has driven up costs, though health care costs have risen at a much slower pace since 2010 than they did in years past. And opponents promise they will somehow make health care cheaper and more readily available, though after all these years of reviling Obamacare they have yet to offer any serious alternative. The reality is that the repeal-at-all-costs crowd is ideologically opposed to any government role in the health care system, though every other advanced economy in the world has embraced some form of government intervention as the only way to manage costs and ensure universal access.
With a narrow 52-to-48 majority in the Senate, Republicans are seeking to evade a Democratic filibuster by instructing congressional committees to draft a budget reconciliation bill to effectively repeal the tax and spending provisions of the A.C.A., gutting the law and increasing the deficit. The House is expected to easily pass a repeal of the A.C.A., since it has already done so dozens of times.
It should perhaps come as no surprise that zealots would resort to using a budgetary maneuver to fundamentally change national policy. But it is still galling, especially because the Republicans have put forward no coherent plan for what would replace the A.C.A. To cope with that rather glaring omission, leaders like the House speaker, Paul Ryan, and Vice President-elect Mike Pence have discussed repealing the law but then delaying its end - claiming political victory while leaving Mr. Obama's plan largely in place - to give Congress and the Trump administration more time to come up with a replacement.
This is cynical politics, of course, but it is also dangerously irresponsible governance. Most experts and much of the health industry - including trade associations representing insurers, hospitals and doctors - have warned that repealing the law without an adequate substitute could be disastrous. Health insurers that see no long-term future for the law will have little incentive to keep offering plans that it would support. And the health insurance marketplaces set up by the A.C.A. will collapse in much of the country if Republicans repeal the individual mandate to purchase health insurance and get rid of or scale back the subsidies available to help people buy policies.
President Obama and congressional Democrats met on Wednesday to discuss how best to protect the A.C.A. They might start by making the case that Mr. Obama has never quite managed to make for the benefits of the law and the dangers of repeal. In particular, they might highlight the stories of the millions of people who voted for Donald Trump and congressional Republicans and now stand to lose their health insurance. A recent Urban Institute study estimated that 956,000 people in Pennsylvania and one million each in Georgia and North Carolina could lose coverage under a repeal done through a reconciliation bill. Most of them are among the very population Mr. Trump said he was running to give a voice to - nationally, 56 percent of those who would lose coverage are white, and 80 percent of adults who would lose insurance have less than a college degree.
The best hope for protecting the major provisions of the A.C.A. rests with the handful of Republicans in the Senate who hold more common-sense views than right-wing ideologues like Mr. Ryan and Mr. Pence. They include: Susan Collins of Maine, who voted against a similar reconciliation bill the Senate passed in 2015 because it would also have defunded Planned Parenthood; Bob Corker and Lamar Alexander, both of Tennessee, who have said they would prefer to repeal once they can replace it with something else; John McCain of Arizona, who told reporters on Tuesday that "we've got to concentrate our efforts to making sure that we do it right so that nobody's left out"; and Rand Paul of Kentucky, who is concerned that repeal will greatly increase the federal debt.
Republican leaders in Congress and Mr. Trump seem eager to show that they can quickly deliver on their campaign promises. If the good of the country is not enough to give them pause, then they might consult their own political self-interest before stampeding to enact policies that will hurt so many Americans.
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November 21, 2014 Friday
Late Edition - Final
Private Sector in Health
SECTION: Section A; Column 0; Editorial Desk; LETTER; Pg. 30
LENGTH: 147 words
To the Editor:
Re ''Health Care Law Recasts Insurers as Obama Allies'' (front page, Nov. 18):
The symbiosis between the government and private insurers under the Affordable Care Act should come as no surprise. The same interdependence characterizes every major health care program. Congress injected a private claims-processing role into Medicare from the start, and private insurers today cover almost 30 percent of enrollees directly.
Medicaid programs in most states use private companies to administer benefits. Government initiatives sustain most of America's private health care sector, and those who seek to repeal the Affordable Care Act would do well to bear this in mind.
ROBERT I. FIELD Philadelphia, Nov. 18, 2014
The writer, a professor of law and public health at Drexel University, is the author of ''Mother of Invention: How the Government Created 'Free Market' Health Care.''
URL: http://www.nytimes.com/2014/11/21/opinion/private-sector-in-health.html
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August 7, 2013 Wednesday
Cheerleader for Health Care Repeal Retires, Blaming Gridlock
BYLINE: JULIET LAPIDOS
SECTION: OPINION
LENGTH: 228 words
HIGHLIGHT: Rodney Alexander voted to repeal health care reform 40 times. In announcing his retirement, he lamented “partisan posturing.”
Rep. Rodney Alexander, Republican of Louisiana, announced on Tuesday that he won't seek re-election, citing "partisan posturing" and "gridlock" in Congress.
"Rather than producing tangible solutions to better this nation, partisan posturing has creative a legislative standstill," he said in a statement. "Unfortunately I do not foresee this environment to change anytime soon. I have decided not to seek reelection, so that another may put forth ideas on how to break through the gridlock and bring about positive change for our country."
It's hard to disagree with Mr. Alexander's characterization of Capitol Hill, but his statement makes for surreal reading nonetheless because the Congressman has voted to repeal health care reform 40 times. For those not keeping track, that's every possible occasion. Just last Friday he supported H.R. 2009, otherwise known as the "Keep the IRS Off Your Health Act of 2013," which would prohibit the Secretary of the Treasury from enforcing the Affordable Care Act.
Jon Lovett, a former speechwriter for President Obama, pointed out this fact on Twitter yesterday and we confirmed it with Mr. Alexander's press office.
The House Republicans' Ghoulish Defunding Rally
What's More Unpopular Than Health Care Reform?
Ted Cruz Plays Two Truths and a Lie
Mitch McConnell Tries Leadership, Then Backs Away
The 'Just Say No' Approach to Governing
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(You're the Boss)
June 4, 2014 Wednesday
Would You Try This Health Insurance Strategy With Your Company?
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 430 words
HIGHLIGHT: A number of companies are offering plans that effectively allow companies to reimburse employees for the individual insurance they buy. The problem is that the Internal Revenue Service may not approve — and the penalties could be big.
In March, we interviewed Dr. Ezekiel J. Emanuel, a doctor who advised the Obama administration on the Affordable Care Act. Dr. Emanuel had just published a book in which he predicted that within a decade, private employers would largely abandon providing health insurance to employees. This, he said, would happen even though such coverage benefits from a big tax break.
Q.
Won't losing the tax break on the coverage be painful for middle-class employees who make too much to qualify for subsidies?
A.
Well, there may be ways of their employer not providing them insurance but providing them a way to get insurance that allows them to keep the tax exclusion. You have to go into the innards of what it means for the employer to sponsor the insurance. But I'm sure they've got a lot of lawyers working on it.
He was right about that. This week, The Times reports on a service offered by Zane Benefits that effectively allows companies to reimburse employees for the individual insurance they buy. Many employers are finding that individual insurance can be 30 to 40 percent cheaper than comparable coverage in a small group plan. And for low-income employees who are eligible for government subsidies to help with the purchase, the savings to the company can be twice that, according to Gary Adkins, an insurance agent who is fond of the Zane plan.
The problem for Zane and a handful of similar companies, as well as for their customers, is that the Obama administration and the Internal Revenue Service appear to be opposed to such arrangements.
Lawyers and lobbyists who have spoken with regulators said their concerns were practical. For example, regulators have said they fear what might happen to the individual market if companies that self-fund their insurance use these plans as a mechanism to off-load their sickest employees, those with the highest medical bills. And they say they believe it is unfair for an employee with an untaxed benefit to also receive a subsidy from the individual insurance exchange. "It gives a false sense of affordability to the exchange," said Seth Perretta, a regulatory lawyer in Washington. "And it presents two people who aren't equal" - because one has a tax-free benefit and the other does not - "as equal."
An employer that chooses to adopt such a plan could face a hefty fine if the I.R.S. decides the plan does not comply with the new health law. What do you think? Should companies be allowed to use tax-free money to reimburse employees for insurance bought on the individual market? As a small-business owner, would you take the risk?
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September 11, 2013 Wednesday
A Health Insurance Offer for the Busy Start-Up
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 889 words
HIGHLIGHT: Young Entrepreneur Council says it wants to save business owners the time and effort of figuring out health insurance. But there may be a price.
Start-ups - hungry, lean, facing an uncertain future - are different from other businesses. So it is reasonable to think that start-ups might have different needs when it comes to health insurance. Now, one organization istrying to profit from this distinction, real or imagined, by marketing health insurance specifically to start-ups almost anywhere in the country.
On Monday, the Young Entrepreneur Council, an invitation-only network of successful company founders, introduced StartupInsurance.com, a Web site where nascent companies can buy health insurance and supplemental policies like dental insurance. "We're trying to bring a level of trust and transparency to a community that we understand very well here," said Scott Gerber, founder of the Young Entrepreneur Council. "We bring the curation and the knowledge of the need of our constituency." The council has simultaneously introduced FreelancerHealthcare and SmallBusinessInsurance, Web sites that sell insurance to those segments of the market.
Certainly the effort makes sense for the for-profit Young Entrepreneur Council. It has used its network of nearly a thousand entrepreneurs to build an online brand for helping small businesses and will receive a fee for every client it refers to the insurance carriers marketing the plans, principally Assurant Health. Eventually, the council plans to market other business services to small companies. The question is whether the sites and their health offerings make sense for start-ups and other entrepreneurs.
Mr. Gerber said start-ups wanted insurance that was affordable and transparent and that complied with the requirements of the Affordable Care Act, which take effect in 2014. But desiring these would not seem to distinguish start-ups and other entrepreneurs from anybody else - what company would not want to buy insurance that is inexpensive, easy to understand, and compliant with regulations?
But in fact, some of the individual health plans the freelance and start-up sites are offering will not comply with the health care law's provisions for providing minimum value. That means that the people who buy them will be subject to the penalty of the individual mandate. Mr. Gerber said that some entrepreneurs might prefer to absorb the mandate penalty in exchange for cheaper, if less extensive, coverage. "It's important to give a choice," he said.
Asked what particular attributes of insurance would appeal specifically to entrepreneurs and start-ups, he said that they could count on the Young Entrepreneurs Council to represent their interests in a shifting landscape - to figure out the complexities of the changing health insurance markets for them. "We sit in the middle of an ecosystem and literally work with thousands of entrepreneurs a day, so we're hearing them, but they also trust us," Mr. Gerber said. "What we're saying is that if you trust what Y.E.C. has been about and continues to be about, then you understand that we put a tremendous amount of time, energy and resources into putting this entire experience and package together. We've done the homework for them."
Mr. Gerber described his partner, Assurant, as "one of the largest specialty health care providers specifically working with self-employed individuals." Mr. Gerber said insurance was available in every state except, Maine, Massachusetts, and Vermont.
But Mr. Gerber said that he could not discuss the details of the plans - including what they will cost - for legal reasons, because he is not a broker. A spokeswoman for Assurant, Mary Hinderliter, said that the plans at all three sites were the same plans Assurant already offered. Though the council is marketing the insurance through three different portals, for three different audiences, the sites appear nearly identical. Mr. Gerber said there were some small differences across the sites, but he declined to identify them, except to note that the freelancer portal would not offer group insurance.
Ms. Hinderliter said Assurant's major medical plans were not meaningfully different from plans that would be available in the insurance markets, known as exchanges, scheduled to begin operating in 2014 under the health care law. (Assurant will not participate in the exchanges until 2015, according to Ms. Hinderliter.) In the exchanges, both individuals and small businesses can comparison shop for insurance across carriers, and plans. Mr. Gerber's contention is that entrepreneurs have neither the time nor the interest in diving so deeply into an ancillary task. But some of the council's clients may miss out on an opportunity - individuals and businesses that are eligible for tax credits to offset the cost of health insurance will only be able to use them if they purchase insurance from an exchange.
Asked to comment about this, Mr. Gerber said, "We were going to do this regardless of whether the Affordable Care Act came to be or not, regardless of the state exchanges. This is our take on how to do it.
"There's a big need here whether the government's involved or not, and we're hoping to help as many people as we can."
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This Week in Small Business: Does Yelp Help?
Today in Small Business: Gratuity Not Included
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August 3, 2015 Monday
Late Edition - Final
A Health Care Safety Net the Public Loves
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 18
LENGTH: 420 words
Recent public surveys show that Americans strongly support Medicare and Medicaid, the twin pillars of the health care safety net, and that approval of the Affordable Care Act, President Obama's health care reform law, is steadily rising. The popularity of these three government programs is a stiff warning to critics, mostly Republicans, who seek to radically change or demolish them.
Last month, the Kaiser Family Foundation reported that a majority of the public and the vast majority of beneficiaries support Medicare, the federal program for elderly and disabled Americans, and Medicaid, the federal-state program for the poor. Majorities of Democrats, independents and Republicans all favor keeping Medicare as it is rather than converting it, as many Republican politicians have urged, to a program in which each enrollee would be given a fixed dollar contribution to buy health insurance.
There are legitimate concerns that the financial condition of Medicare could deteriorate as the baby boomers age and as health care costs continue to rise faster than normal inflation. Polls analyzed by Harvard researchers in the New England Journal of Medicine in 2013 showed the public strongly in favor of reducing Medicare spending to improve the long-term financial outlook of the program, but strongly opposed if the cuts would be used to reduce the deficit or pay for tax cuts.
As for Medicaid, the Kaiser survey found that more than 60 percent of the public opposes converting it from an entitlement, in which the federal and state governments split the cost for everyone who qualifies, to a block grant, in which the federal government would provide a fixed amount of money. Under that approach, the states would be struggling to keep all costs within that amount, which might well require reducing benefits.
The Affordable Care Act is also gaining support. The latest Gallup poll, published in July, showed that Americans' approval of the law rose to 47 percent, the highest level since 2012. (About 83 percent of Democrats supported the law compared with 14 percent of Republicans.) Other surveys in June and July have also shown a closely split verdict, which is an improvement over earlier polls showing greater public opposition.
The growing approval of the act is likely to get stronger as more people gain coverage and benefit from it. These voters need to throw their political weight behind candidates for Congress and the White House in 2016 who will work to improve the law, not repeal or weaken it.
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January 17, 2017 Tuesday 00:00 EST
Cuomo and Trump to Meet About 'Issues of Importance to New York'
BYLINE: JESSE McKINLEY
SECTION: NYREGION
LENGTH: 508 words
HIGHLIGHT: Gov. Andrew M. Cuomo and President-elect Donald J. Trump will meet at Trump Tower on Wednesday for the first time since the election.
ALBANY - Just days before President-elect Donald J. Trump's inauguration, Gov. Andrew M. Cuomo of New York will meet with Mr. Trump on Wednesday, the first face-to-face meeting between the two men since the election.
The meeting will take place at Trump Tower, and the topics will include infrastructure, the Affordable Care Act and "issues of importance to New York," according to Melissa DeRosa, the governor's chief of staff.
The meeting comes against a complicated backdrop: Mr. Cuomo believes that New York, the home state of both men, faces potentially harrowing financial consequences, a loss of more than $3 billion, from Mr. Trump's planned repeal of the health care law. Mr. Trump has said the law should be repealed and replaced, and has suggested that he has a plan in hand, but has not offered any details.
Mr. Cuomo, who spoke to the president-elect shortly after the election, initially offered an optimistic assessment that Mr. Trump's election could be "a bonus" for New York, citing his understanding of building, infrastructure and urban areas. Nonetheless, Mr. Cuomo said he wanted to see how Mr. Trump would handle federal programs, like housing, that he called "very important to New York."
Since then, the governor has been critical of Mr. Trump, saying that the state has "fundamentally different philosophies than what Donald Trump laid out in his campaign," and questioning the qualifications of some of his cabinet nominees. In a State of the State address in Manhattan last week - one of six he gave around the state - Mr. Cuomo appeared to be positioning himself, and the state, as a liberal bulwark against Mr. Trump's planned policies.
"Let the great State of New York serve as a safe harbor for our progressive principles and social justice that made America," the governor said.
Such language has inspired talk that Mr. Cuomo might be planning a run for higher office himself, though the governor denies that assertion.
On Tuesday evening, however, even as Mr. Cuomo unveiled his state budget for the coming fiscal year, he returned to the importance of federal money feeding state coffers.
"I think it would be helpful to him to have a discussion about how these issues effect the practical," the governor said of Mr. Trump during a briefing at the Executive Mansion, adding that he wanted to inform the president-elect about "what does Medicaid mean for the State of New York, what happens if the Affordable Care Act goes away and there are uninsured people?"
The governor added that he felt Mr. Trump knew about some of the persistent problems in New York City - "He knows how bad homelessness is," Mr. Cuomo said - and about the importance of development.
And while the two men are from different political parties, Mr. Cuomo also complimented the president-elect, saying, "He's very good with numbers."
Mr. Cuomo added: "Having gone through the budget, I know the numbers for this state and what it would mean.
"I can give him a context," he said. "And I want to make sure he has that context when he's making these decisions."
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February 19, 2017 Sunday
Late Edition - Final
How a Tax Code Overhaul May Affect You
BYLINE: By CHARLES DELAFUENTE
SECTION: Section BU; Column 0; Money and Business/Financial Desk; Pg. 10
LENGTH: 1133 words
When Donald J. Trump was campaigning for president, he said that he wanted ''to put H&R Block out of business'' by simplifying the income tax laws.
But tax simplification isn't a simple task, and while Mr. Trump singled out the company again on Wednesday, saying it would not be happy with what he had in mind, changing the tax code isn't something he can do by himself.
The tax law, which has thousands of sections and subsections, is just that: law. A new law, or a change to an existing one, must be passed by both houses of Congress before it is signed by the president.
There is not much doubt that some changes are coming to the tax code, though the all-important details aren't clear.
The House Republican leadership released a tax plan outline last year, while Mr. Trump has said that he will work with Congress to pass what he calls the Middle Class Tax Relief and Simplification Act, provisions of which he proposed in September. On Thursday, he said that ''tax reform is going to happen fairly quickly'' but that dealing with the Affordable Care Act had to come first. He said that would happen next month.
The two plans differ -- for instance, on whether to limit deductions for real estate taxes and mortgage interest. The changes that may actually result are still a mystery.
It is unlikely that changes in the tax code would affect tax returns that must be filed this year, which cover last year's income and deductions.
With the caveat that any list of forthcoming changes is speculative, here are major items that are under discussion in Washington and that may affect your tax returns:
Tax rates. The Trump plan and the House plan would both cut the top rate to 33 percent from 39.6 percent, raise the lowest rate to 12 percent from 10 percent, and collapse the number of brackets -- different tax rates at different income levels -- to three from seven. The Senate leadership has not yet weighed in on rates.
Itemized deductions. The Trump plan would cap itemized deductions at $200,000 a year for married couples filing jointly and $100,000 for single filers. To take an itemized deduction, you subtract the specific item from your income, which reduces your taxes. But under the Trump plan, the standard deduction would increase, so many people who file itemized returns now may not find it in their interest to do so in the future.
Mortgage interest and real estate tax deductions. The itemized-deductions cap proposed by Mr. Trump would effectively limit interest and real estate tax deductions for the owners of expensive homes -- a backdoor way of curtailing them. There has been talk in Congress for years about limiting or eliminating itemized deductions for mortgage interest (interest payments on up to $1 million in mortgage debt are now deductible), usually in conjunction with raising the standard deduction, although these changes are not part of the current House plan. The real estate industry has lobbied strenuously to retain the interest and real estate tax deductions, which are important for many homeowners.
Filing status. The president's plan would eliminate the head-of-household filing category, which gives more favorable rates to some unmarried people who can claim dependents than to single taxpayers.
Standard deduction. Mr. Trump would increase the standard deduction to $15,000 from $6,350 for single filers and to $30,000 from $12,700 for married couples.
Personal exemptions. Mr. Trump has also proposed doing away with exemptions for taxpayers and their dependents, which are worth $4,050 each. (An exemption is like a deduction; you can subtract the amount of the exemption from your income and cut your tax bill.) Those exemptions now begin to phase out at an adjusted gross income of $259,400 for single taxpayers and $311,300 for married couples, and disappear completely for incomes above $381,900 for single filers and $433,800 for couples.
Carried interest. Mr. Trump has said that carried interest, which is income earned by general partners in private equity and hedge funds, should be taxed as ordinary income. Under current law, it is taxed at the lower capital gains rate.
Dependent-care deductions. Under the Trump plan, even if taxpayers don't itemize, they would be given more liberal credits for care of children and older adult dependents. The credits would not be available to individuals with adjusted gross incomes of more than $250,000 or to couples with more than $500,000 in income. Tax credits are more valuable to taxpayers than deductions, because credits are subtracted from the tax that is owed, not from the income on which that tax is based.
Alternative minimum tax. Under the Trump plan, this tax, known as the A.M.T., which limits some deductions for many high earners and effectively raises the amount of tax they owe, would be repealed.
Capital gains tax rates. The Trump plan does not call for lowering the rates on long-term capital gains, which now top out at 20 percent for the highest earners -- single filers with adjusted gross incomes above $415,050, and couples with incomes above $466,950. The House plan would lower capital gains rates.
Capital gains Medicare surtax. Mr. Trump proposes ending the 3.8 percent surtax on investment income from capital gains, which affects single taxpayers with adjusted gross incomes over $200,000 and couples with incomes over $250,000. (If the income over those thresholds is less than the capital gain, the lower amount is subject to the 3.8 percent tax.) That surcharge was instituted as part of the Affordable Care Act. If the health law is repealed, the surcharge will probably be eliminated.
In addition, repeal or revision of the Affordable Care Act may affect these areas:
Medical deduction. Taxpayers who itemize can currently deduct medical expenses that amount to more than 10 percent of their adjusted gross income. That amount rose from 7.5 percent (where it remains for people over 65) as part of the Affordable Care Act. If the act is repealed, will the rate go back down? That's uncertain.
Fines for not having medical insurance. This penalty, part of the Affordable Care Act, is not really an income tax, but it is reported on tax returns and many people think of it as one. It is based on a complex sliding scale, and can be $695 a year for an individual and $2,085 for a family, or in some cases significantly more. That penalty could be eliminated.
Medicare payroll tax. This isn't really an income tax, either, although the amount paid appears on the standard W-2 income statements that employers fill out. The Affordable Care Act raised the payroll tax by 0.9 percent on single taxpayers with gross wages of over $200,000 and couples with incomes over $250,000. That will presumably be eliminated if the act is dismantled.
URL: http://www.nytimes.com/2017/02/16/business/yourtaxes/how-a-tax-code-overhaul-may-affect-you.html
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The New York Times
March 10, 2017 Friday
Late Edition - Final
In Health Bill's Details, a Republican Civil War
BYLINE: By JEREMY W. PETERS; Emmarie Huetteman contributed reporting.
SECTION: Section A; Column 0; National Desk; Pg. 21
LENGTH: 1286 words
WASHINGTON -- Republicans are rarely as exercised as when they are fighting with themselves.
And as the House debates how to best dismantle the Affordable Care Act, a familiar array of interest groups with deep pockets, incensed talk radio hosts and online agitators is again assuming its posture of aggression toward the House Republican leadership.
''Swampcare,'' the writer and radio personality Erick Erickson scoffed at the new American Health Care Act, the culmination of seven years of promises to repeal and replace President Barack Obama's signature domestic achievement. ''Obamacare 2.0,'' declared Breitbart.com. ''RINOCARE,'' Mark Levin wrote on Twitter, using the acronym for Republican in Name Only.
Political groups backed by the billionaire brothers Charles and David Koch and other powerful players on the right, such as Club for Growth and Heritage Action for America, have come out quickly and strongly against the bill. Some have threatened to punish lawmakers by docking their conservative ratings on the influential ''scorecards'' they distribute to voters. Activists are already swarming Capitol Hill and demanding that Congress take a harder line and pass a repeal measure that would leave no trace of the Affordable Care Act.
''I feel lied to,'' said Anna Beavon Gravely, the deputy state director of the North Carolina chapter of Americans for Prosperity, a Koch-backed group that is funding a grass-roots push against Republicans in Congress who want to stop short of an outright repeal.
''We trusted you because you said you were going to do something about this. And this is not it. Not even close,'' she added as she prepared to set out for the offices of North Carolina lawmakers with other activists from her state.
The displeasure is forcing an uncomfortable reckoning in the Republican Party much earlier and in a much more disruptive way than many think is constructive. And it has many conservatives asking why -- now that they control both houses of Congress and the White House and have remained largely united so far -- they are picking a fight with each other.
The criticism from the right has grown so harsh that President Trump asked leaders of several conservative groups in an Oval Office meeting on Wednesday to tone it down. He was especially troubled, one participant said, by the comparisons of the plan to ''Obamacare lite,'' which he said was inaccurate and harmful to their shared cause of gutting the current law.
One senior White House official described the meeting as ''tough.'' Referring to the president, the official said: ''He listened. They vented.''
After the meeting, the White House appeared more confident about the prospects in the House for the health care overhaul. In a meeting with conservative leaders in the Oval Office on Wednesday, Mr. Trump said he anticipated the most trouble in the Senate, where Republican moderates and conservatives are opposing the plan for different reasons. He said he was prepared to pressure holdout senators by having the kind of stadium-style rallies he had during his presidential campaign.
Unified government was supposed to eliminate some of the infighting that plagued the Republicans during the Obama years, when the party's right flank brought down a House speaker, defeated a House majority leader and blocked another majority leader's ascent. Instead, it is underlining the difficulties of running Washington now that their party bears full responsibility.
''For a while, it did seem like Trump's victory had transcended the old political battles,'' said Matt Lewis, a conservative author, who added that the fighting was doubly odd because the repeal was not an issue central to Mr. Trump's immigration- and jobs-themed campaign. ''This is not why people elected Donald Trump. And yet here we are.''
As they find themselves sudden targets of a well-organized and well-financed opposition from within, some Republicans are beginning to question whether the squabbling is ultimately self-defeating. And their doubts raise a new question for this Republican faction that has been mocked as the ''Party of No'': Can they ever get to yes?
''I fully respect people on the outside -- who don't have to take a vote or produce an outcome -- who strive for perfect,'' said Senator Thom Tillis of North Carolina, one of the Republicans who found activists in their offices this week. Perfect, he said, is never as attainable as people think. ''But we're going to get good here.''
Stopping government-mandated health care has been a cause unifying conservatives since Mr. Obama began talking about it as a presidential candidate nine years ago. Perhaps no other issue created as much energy among conservative voters, helping Republicans make historic gains in Congress as they railed against the law as an egregious government overreaching into a vast part of the economy.
But differences over how exactly to unravel the Affordable Care Act have long divided Republicans, even when the stakes were low and they knew that whatever they passed in Congress would be vetoed by Mr. Obama. In 2013, differences within the Republican Party over defunding it led to a 16-day government shutdown.
Back then, the fault lines in the debate were largely the same: hard-line conservatives butting up against the party leadership, which they accused of not acting aggressively enough.
But as much as the squabbling seems the same, there is one crucial difference: They are firing with real bullets now.
''We're on the hook this time,'' said Representative Dave Brat, Republican of Virginia, who is part of the group of conservatives pushing for an outright repeal. ''This one counts.''
That they are firing some of those bullets at one another seems to be less of a concern the more conservative you are.
Representative Raul Labrador of Idaho, an opponent of the House bill who along with Mr. Brat is a member of the House Freedom Caucus, the driving force on Capitol Hill behind the resistance, said that any Republicans who will not vote to fully repeal the law will not be keeping a promise they made to voters. ''And they can go back to their districts and explain to the American people why they lied,'' he said.
Conservatives see many of the same problems in the Republican leadership plan today that bothered them about the Democrats' 2010 health care bill: It extends a taxpayer-funded subsidy to help individuals buy insurance; though it revokes the Affordable Care Act's mandate that nearly all Americans have insurance, it replaces the mandate with a new penalty if a consumer buys insurance after letting coverage lapse; it was negotiated largely without consulting the rank and file; and, they insist, its benefits could go toward people who should not receive them, like undocumented immigrants.
Matt Schlapp, the chairman of the American Conservative Union, echoed a concern that many conservative activists have voiced about not being briefed or consulted on the plan. ''It goes a long way when you hear people out,'' he said. ''And there are a lot of natural allies that this caught by surprise as much as it did Democrats.''
The unhappiness on the right could be especially worrisome for Speaker Paul D. Ryan, whose status as a favorite target of the conservative base seemed to fade in the wake of Mr. Trump's election.
Now, many conservatives appear willing to reopen the wounds of old leadership fights. Some of them have already taken to mocking the repeal plan with what they consider to be the most damning of pejoratives -- not ''Trumpcare,'' as Democrats call it, but ''Ryancare.''
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URL: http://www.nytimes.com/2017/03/09/us/politics/why-republicans-are-battling-republicans-on-obamacare-repeal.html
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March 10, 2014 Monday
Late Edition - Final
Little-Known Health Act Fact: Prison Inmates Are Signing Up
BYLINE: By ERICA GOODE
SECTION: Section A; Column 0; National Desk; Pg. 1
LENGTH: 1216 words
In a little-noticed outcome of President Obama's Affordable Care Act, jails and prisons around the country are beginning to sign up inmates for health insurance under the law, taking advantage of the expansion of Medicaid that allows states to extend coverage to single and childless adults -- a major part of the prison population.
State and counties are enrolling inmates for two main reasons. Although Medicaid does not cover standard health care for inmates, it can pay for their hospital stays beyond 24 hours -- meaning states can transfer millions of dollars of obligations to the federal government.
But the most important benefit of the program, corrections officials say, is that inmates who are enrolled in Medicaid while in jail or prison can have coverage after they get out. People coming out of jail or prison have disproportionately high rates of chronic diseases, especially mental illness and addictive disorders. Few, however, have insurance, and many would qualify for Medicaid under the income test for the program -- 138 percent of the poverty line -- in the 25 states that have elected to expand their programs.
Health care experts estimate that up to 35 percent of those newly eligible for Medicaid under Mr. Obama's health care law are people with histories of criminal justice system involvement, including jail and prison inmates and those on parole or probation.
''For those newly covered, it will open up treatment doors for them'' and potentially save money in the long run by reducing recidivism, said Dr. Fred Osher, director of health systems and services policy for the Council of State Governments Justice Center.
He added that a 2009 study in Washington State found that low-income adults who received treatment for addiction had significantly fewer arrests than those who were untreated.
In Chicago, inmates at the Cook County Jail are being enrolled in Medicaid under the health care law as part of the intake process after they are arrested; the county has submitted more than 4,000 applications for inmates since Jan. 1.
In Colorado, state prisoners are being signed up when they need extended hospitalization; 93 applications for inmates and 149 for parolees have been submitted so far.
In the Portland area, more than 1,200 inmates have been enrolled through the state exchange, Cover Oregon, while Delaware and Illinois expect to start soon.
Devon Campbell-Williams, an inmate serving time for assault in the Multnomah County Inverness Jail in Portland, Ore., applied for Medicaid in January with the help of an eligibility worker hired by the county to enroll inmates. When he gets out of jail in May, he said, he will have health insurance for the first time, coverage that will allow him to get treatment for his ankle, which he broke in 2007 and has been bothered by ever since.
''It's going to mean a lot,'' Mr. Campbell-Williams said, adding that in the past, ''I just went to the hospital, that was really about it.''
Opponents of the Affordable Care Act say that expanding Medicaid has further burdened an already overburdened program, and that allowing enrollment of inmates only worsens the problem. They also contend that while shifting inmate health care costs to the federal government may help states' budgets, it will deepen the federal deficit. And they assert that allowing newly released inmates to receive Medicaid could present new public relations problems for the Affordable Care Act.
''There can be little doubt that it would be controversial if it was widely understood that a substantial proportion of the Medicaid expansion that taxpayers are funding would be directed toward convicted criminals,'' said Avik Roy, a senior fellow at the Manhattan Institute, a conservative policy group.
Language in the health care law also allows private insurance plans purchased through state exchanges to cover health care for people who are in jail awaiting trial, even in states that have not expanded Medicaid. But few prisoners have incomes high enough to afford the plans, even with federal subsidies, and most state and county correction systems are not yet set up to benefit from that coverage.
In the past, states and counties have paid for almost all the health care services provided to jail and prison inmates, who are guaranteed such care under the Eighth Amendment. According to a report by the Pew Charitable Trusts, 44 states spent $6.5 billion on prison health care in 2008. In Ohio, health care for prisoners cost $225 million in 2010 and accounted for 20 percent of the state's corrections budget. Extended hospital stays -- treatment for cancer or heart attacks or lengthy psychiatric hospitalizations, for example -- are particularly expensive.
Stuart Hudson, managing director of health care for Ohio's Department of Rehabilitation and Correction, said his department, which plans to start enrolling inmates in Medicaid when they have been in the hospital for 24 hours, expects to save $18 million a year through the practice, ''although it's hard to know for sure, because there's other eligibility factors we have to keep in mind.''
Nancy Griffith, Multnomah County's director of corrections health, said the county expected to save an estimated $1 million annually in hospital expenses by enrolling eligible inmates and passing the costs to the federal government.
More money could be saved over the long term, she added, if connecting newly released inmates to services helps to keep them out of jail and reduces visits to emergency rooms, the most expensive form of care.
''The ability for us to be able to call up a treatment provider and say, 'We have this person we want to refer to you and guess what, you can actually get payment now,' changes the lives of these people,'' Ms. Griffith said.
Rick Raemisch, executive director of Colorado's Department of Corrections, said that billing Medicaid for hospital care would save ''several million dollars'' each year. But as important, he said, was the chance to coordinate care for prisoners after their release.
About 70 percent of prison inmates in the state have problems with addiction, he said, and 34 percent suffer from mental illness.
Without health coverage, inmates leave prison with 30 days' worth of medication and are then mostly left to their own devices.
''If they go off their medication, oftentimes it can once again lead to more criminal activity,'' Mr. Raemisch said. ''So by keeping them medicated and keeping them mentally healthy, it really helps us in our re-entry efforts.''
It costs far more to keep an inmate in prison than to provide treatment outside. Yet most health care experts agree that health coverage alone is not enough to keep chronic offenders on track.
As essential as health insurance is for people trying to put together their lives after being incarcerated, the challenge of getting them into treatment, when they often did not have housing or jobs, was ''a whole other kettle of fish,'' said Bradley Brockmann, executive director of the Center for Prisoner Health and Human Rights in Providence, R.I. He is an author articles in a collection on the topic in the March issue of The Journal of Health Affairs.
''The potential for this is so huge,'' he said, ''and it will take a lot more than just getting returning prisoners their Medicaid cards.''
URL: http://www.nytimes.com/2014/03/10/us/little-known-health-act-fact-prison-inmates-are-signing-up.html
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GRAPHIC: PHOTO: Devon Campbell-Williams, an inmate in Portland, Ore., will have insurance for the first time under the Affordable Care Act. (PHOTOGRAPH BY LEAH NASH FOR THE NEW YORK TIMES) (A13)
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(Taking Note)
July 31, 2012 Tuesday
If It Works in Israel...
BYLINE: ANDREW ROSENTHAL
SECTION: OPINION
LENGTH: 373 words
HIGHLIGHT: Mitt Romney praised Israel's health care system yesterday. Does he know about our ally's individual requirement?
During his trip to London, Mitt Romney insulted his hosts by questioning their Olympic preparedness. He did not make the same mistake in Israel (which no presidential aspirant of either party would dare criticize). At a breakfast fundraiser in Jerusalem on Monday, he had nothing but nice things to say about our ally. But in flattering Israel, he raised more doubts about his political abilities than in disparaging Great Britain.
As I mentioned yesterday, he said that Israelis are wealthier than Palestinians due to cultural differences. A senior aide to Mahmoud Abbas called that suggestion "racist," and bloggers everywhere wondered
As I didn't mention, he also praised Israel's health care system. "Do you realize what health care spending is as a percentage of the GDP in Israel?" he asked. "Eight percent. You spend eight percent of GDP on health care. You're a pretty healthy nation. We spend 18 percent of our GDP on health care, 10 percentage points more . We have to find ways - not just to provide health care to more people, but to find ways to fund and manage our health care costs." Bloggers everywhere wondered,
I really would like to know if Mr. Romney- who as governor of Massachusetts passed a healthcare bill including an individual mandate before suggesting the president adopt the idea for the country before promising to "get rid of Obamacare"-bothered to research Israel's system. Because as Think Progress noted, "every Israeli citizen has the obligation to purchase health care services through one of the country's four HMOs since government officials approved the National Health Insurance Law in 1995." Moreover, Israelis "pay 40 percent of their HMO's costs through income-related contributed collected through the tax system, and the state pays the remaining 60 percent."
If Mr. Romney's serious about finding ways "not just to provide health care to more people, but to find ways to fund and manage our health care costs," he could start by endorsing the Affordable Care Act-a more market-oriented version of the Israeli system, which (as even Mr. Romney admits) works quite well.
Roberts Hits the Reset Button
Health Care Confusion
Healthcare: What Might Have Been
Romney's Health Care Plan
Romney's Charm Offensive
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November 16, 2016 Wednesday 00:00 EST
Republican Falsehoods About Obamacare;
Taking Note
BYLINE: TERESA TRITCH
SECTION: OPINION
LENGTH: 378 words
HIGHLIGHT: Paul Ryan and others claim that Obamacare is hurting people with Medicare and employer-provided insurance. They're wrong.
A repeal of the Affordable Care Act, which the Republicans have been threatening for years, would obviously be unpopular with the 20 million people who have received coverage under the A.C.A.
But Republican leaders don't seem too concerned with those people. Instead, they are trying to convince people who don't rely on the A.C.A. that repeal of the law would leave them better off.
Paul Ryan, for instance, said on on Fox News on Thursday, that "because of Obamacare, Medicare is going broke." That statement is false. According to the Medicare trustees, cost controls in the A.C.A. are one of the reasons that the system's hospital trust fund is projected to remain solvent through 2028 - 11 years longer than before the A.C.A. was enacted.
A similar claim by critics of the A.C.A. is that the law is driving up the cost of employer-provided insurance, which covers 154 million people. A new study by the Commonwealth Fund, which compares costs in the five years before and after 2010, when the A.C.A. was enacted, rebuts that claim.
In most states, the pace of growth in premium costs and deductibles has slowed since 2010. Nonetheless, employees do spend a greater share of their incomes for health coverage because of continued slow wage growth through 2014. Another big factor, especially across the South, is that employers in low-income states tend to offer workers plans that are costlier in terms of employees' premium contributions and plan deductibles. The result is a rise in the share of income going toward health coverage.
In Mississippi, for example, 14.7 percent of median household income went to pay for premiums and deductibles on employer-provided polices in 2015. In Texas and three other southern states, plus Arizona and New Mexico, households paid 12 percent or more. By contrast, in the high income states of Maryland and Massachusettes, such costs were less than 8 percent of median income; in California, Connecticut, New York and several other relatively affluent states, they ranged from about 8 percent to less than 10 percent.
There are no good reasons to repeal the A.C.A. It is helping 20 million people directly and it is not harming hundreds of millions who are insured outside the A.C.A.
Teresa Tritch is a member of the editorial board.
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October 26, 2016 Wednesday
Late Edition - Final
Taming Affordable Care Act Premiums
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 30
LENGTH: 553 words
The Affordable Care Act has improved and expanded health insurance to cover millions more Americans. But it is far from perfect, and the sharp increase in premiums for plans sold under the program shows some of the problems that the next president and Congress need to fix.
Premiums will increase by 25 percent on average for midlevel plans next year, according to the Department of Health and Human Services, but most Americans will be largely insulated from price increases by federal subsidies. About 85 percent of the 10.5 million people who bought insurance through the online health exchanges this year received subsidies; that proportion is likely to increase in 2017 as premiums rise.
Premiums are going up because many insurers underpriced plans when they started selling policies in 2013; not enough healthy, younger people signed up; and those who did used more medical care than the insurers had anticipated. As a result, companies like UnitedHealth and Aetna have stopped selling health plans in many parts of the country and the providers that remain have raised prices. Premiums have gone up most in states like Alabama, Arizona, Oklahoma and Tennessee that have three or fewer insurers selling Affordable Care Act plans.
Premiums are rising much more modestly in states where there is more robust competition among insurers. For example, the average cost of the second-lowest ''Silver'' level plan, the benchmark used by federal officials to analyze the market, will increase by 7 percent in California, 5 percent in New Jersey and 2 percent in Ohio.
Even with the big premium increases, health experts say that plans on the exchanges generally cost less and provide access to more medical care than the plans that they replaced. All told, the law has helped 20 million people gain coverage, including those who became eligible for Medicaid and young adults allowed to stay on their parents' policies, pushing the portion of the population without insurance to less than 10 percent for the first time in history. (About 150 million people are insured through employer plans.)
With open enrollment starting on Nov. 1 and ending on Jan. 31, the federal and state governments ought to make every effort to increase enrollment to spread the insurance risk over a larger population. For instance, of the 27.2 million people who still do not have health insurance, about 5.3 million are eligible for federal tax subsidies and may not realize it, according to a recent report by the Kaiser Family Foundation. People without health insurance will have a tax penalty of about $700 a year in 2017, up from about $400 in 2016. One way to lift enrollment would be to increase the penalty.
Congress and the next president could further strengthen the health care law by offering subsidies to middle-income families who currently receive little or no help. Lawmakers should also consider applying to the health care exchanges the kind of reinsurance program Congress has used to encourage insurers to participate in Medicare's Part D prescription drug benefit program. The Affordable Care Act's flaws are fixable, but only if politicians from both parties work together in good faith.
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URL: http://www.nytimes.com/2016/10/26/opinion/the-acas-premium-increases-are-a-fixable-problem.html
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January 3, 2017 Tuesday 00:00 EST
Turmoil Overshadows First Day of Republican-Controlled Congress
BYLINE: JENNIFER STEINHAUER and ROBERT PEAR
SECTION: US; politics
LENGTH: 1403 words
HIGHLIGHT: It was a rocky start to a period in which Republicans had promised an end to Washington gridlock if they controlled both Congress and the White House.
WASHINGTON - The Republican-controlled Congress opened the turbulent Trump era in Washington on Tuesday, as the new Senate moved instantly to begin the repeal of President Obama's signature health care law while the House descended into chaos in an ill-fated attempt to gut an independent congressional ethics office.
On a day usually reserved for pomp, constitutionally mandated procedure and small children parading around in fancy dresses, Congress instead pitched itself into partisan battles.
Speaker Paul D. Ryaneasily won re-election, but not before the embarrassment of having his members defy him by voting to eliminate the ethics office, only to then abandon that effort after a flood of criticism from constituents and Twitter messages from President-elect Donald J. Trump that criticized House Republican priorities.
It was a rocky start to a period in which Republicans had promised an end to Washington gridlock if they controlled both Congress and the White House. There was intraparty conflict and a sense that Mr. Trump, who ran against the Republican establishment, would continue to be openly critical of his own party at times.
As Democrats in both chambers seethed, Senator Mitch McConnell of Kentucky, the majority leader, unveiled the legislative language that could decimate the Affordable Care Act before the crocuses start to bloom in the spring, even if any replacement of the law could take years.
Budget language released on Tuesday gives House and Senate committees only until Jan. 27 to produce legislation that would eliminate major parts of the health care law. Under arcane budget procedures, that legislation would be protected from a Democratic filibuster and could pass the Senate with a simple majority. And debate will begin on Wednesday, before senators have even moved into their new offices.
The dueling over the health law's fate will pull in both the departing and incoming White House administrations as well. On Wednesday, Mr. Obama will visit with congressional Democrats to plot how to resist the planned repeal, and Mike Pence, the vice president-elect, will meet with Republicans to gird them for the fight ahead.
While the Senate action showed Republicans on course to keep campaign promises, the House got off to a messy start, brought on by Republicans who had moved largely in secret on Monday to gut a congressional ethics office against Mr. Ryan's wishes.
That provoked an outcry from both Democrats and voters who flooded House offices with angry calls. "Every left-wing organization is calling my office," said Representative Pete Sessions, Republican of Texas. "And we've told them: 'Thank you very much. We appreciate your feedback.'"
After a hastily called meeting on Tuesday morning among Republicans, the matter was dropped before it could go to the full House floor for a vote.
As the Senate moved to larger legislative matters, the House kerfuffle seemed to cast a shadow over Mr. Ryan, but he tried to brush it off. "There's no sense of foreboding in the House today," Mr. Ryan said after his re-election, "only the sense of potential."
The fight over the House rules was already acrimonious thanks to a piece of the package that would impose $2,500 in fines for filming events on the House floor, a response to Democrats who streamed their overnight sit-in over guns last June using cellphones and video cameras.
In the Senate, Vice President Joseph R. Biden Jr. swore in seven new members and all the incumbents who won their races last year, their colleagues looking on cheerfully, as a cold rain pelted the newly refurbished Capitol dome.
Members of the House and Senate brought along their families - elderly parents with canes, small children tugging at uncomfortable lacy hems - as well as former senators and other special guests. Former Vice President Dick Cheney accompanied his daughter Liz to her swearing-in as a member of the House elected from Wyoming.
Senator Chuck Schumer of New York officially became the Democratic leader and quickly warned Republicans that the minority would be vocal, if not operatic, in resisting much of their agenda and many of Mr. Trump's nominees.
"It is our job to do what's best for the American people, the middle class and those struggling to get there," he said. "If the president-elect proposes legislation on issues like infrastructure, trade and closing the carried interest loophole, for instance, we will work in good faith to perfect and, potentially, enact it. When he doesn't, we will resist."
He added, "If President-elect Trump lets the hard-right members of Congress and his cabinet run the show, if he adopts their timeworn policies - which benefit the elites, the special interests and corporate America, not the working man and woman - his presidency will not succeed."
On Tuesday, the House also adopted rules clearing the way for legislation to roll back the health care law.
The budget blueprint introduced on Tuesday in the Senate is not sent to the president and does not become law, but still clears the way for subsequent legislation that Republicans say will repeal major provisions of the Affordable Care Act.
Republicans bypassed the Budget Committee so they could immediately bring the measure to the floor. Such resolutions are normally developed after weeks of work in the Budget Committee.
Under the plan, four congressional committees - two in the House and two in the Senate - have until Jan. 27 to develop legislation that will be the vehicle for repealing the health care law.
The document does not specify which provisions of the law may be eliminated and which ones may be preserved. Nor does it specify or even suggest how Republicans would replace the Affordable Care Act, which the Obama administration says has provided coverage to some 20 million people who were previously uninsured.
Republicans have said they may delay the effective date of a repeal bill, to avoid disrupting coverage for people who have it and to provide time for Republicans to develop alternatives to the 2010 health law.
The budget blueprint allows Republicans to use savings from repealing major provisions of that law to help offset the cost of future, unspecified measures to help people obtain coverage.
"Americans face skyrocketing premiums and soaring deductibles," said Senator Mike Enzi, Republican of Wyoming and chairman of the Senate Budget Committee. "Insurers are withdrawing from markets across the country, leaving many families with fewer choices and less access to care than they had before - the opposite of what the law promised."
The American Medical Association urged Congress on Tuesday to explain how it would replace the Affordable Care Act. "Before any action is taken through reconciliation or other means that would potentially alter coverage, policy makers should lay out for the American people, in reasonable detail, what will replace current policies," the chief executive of the association, Dr. James L. Madara, said in a letter to congressional leaders.
Representative Nancy Pelosi of California, who engineered the House passage of the health law in 2010, promised this week that Democrats would be just as aggressive in fighting its repeal.
Republicans have said they may delay legislation to replace the health law for several years. Ms. Pelosi said that such a delay would be "an act of cowardice on the part of Republicans," and that "they don't even have the votes to do it" because they have not agreed on a replacement plan.
Democrats also vowed to give Mr. Trump's cabinet nominees rigorous scrutiny.
Senator Dianne Feinstein of California, the highest-ranking Democrat on the Judiciary Committee, has written to Senator Charles E. Grassley of Iowa, the committee chairman, asking to postpone the first scheduled confirmation hearing, set for next week for Senator Jeff Sessions of Alabama, whom Mr. Trump has chosen as attorney general.
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PHOTO: Paul D. Ryan, who easily won re-election as House speaker, swore in members of the 115th Congress on Tuesday. (PHOTOGRAPH BY STEPHEN CROWLEY/THE NEW YORK TIMES)
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Trump and Senate Move Quickly to Repeal Affordable Care Act
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March 25, 2017 Saturday
Late Edition - Final
On What He Really Said, and Whom He Is Blaming for It
BYLINE: By LINDA QIU
SECTION: Section A; Column 0; National Desk; FACT CHECK; Pg. 13
LENGTH: 934 words
WASHINGTON -- Reeling from a major blow to his legislative agenda, President Trump blamed Democrats on Friday after House Republicans rescinded their bill to repeal and replace the Affordable Care Act. He insisted it wasn't an immediate priority anyway.
Here is an assessment of his claims.
Mr. Trump denied that he promised to repeal the health law quickly.
''And I never said -- I guess I'm here, what, 64 days? I never said repeal and replace Obamacare. You've all heard my speeches. I never said repeal it and replace it within 64 days. I have a long time.''
False. Mr. Trump has, of course, repeatedly vowed to repeal and replace former President Barack Obama's signature legislative achievement. While Mr. Trump never specified doing so within 64 days, killing the health care law was part of his 100-day plan, released in October, and he often promised an even more urgent timeline during the 2016 presidential campaign.
At a campaign rally in Sioux City, Iowa, in October 2015, Mr. Trump said repealing the health law would be the ''first thing'' he would do as president.
''We will immediately repeal and replace Obamacare -- and nobody can do that like me. We will save $'s and have much better health care!'' he wrote on Twitter in February 2016.
We will immediately repeal and replace ObamaCare - and nobody can do that like me. We will save $'s and have much better healthcare! -- Donald J. Trump (@realDonaldTrump) February 9, 2016
''When we win on Nov. 8th and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare,'' he said at a rally in November in Valley Forge, Pa.
Mr. Trump blamed the failure of the G.O.P.'s health care bill on the Democrats.
''With no Democrat support, we couldn't quite get there. We were just a small number of votes short in terms of getting our bill passed.''
This is misleading. Democrats have been united in their opposition since the beginning of the fight to repeal and replace the health law. But Republicans did not need Democratic support to pass their legislation.
Republicans needed 215 votes in the House to pass the bill. They have 237 out of the 435 seats, meaning they could afford only 22 party defections. Before the bill was pulled, 33 Republicans were opposed.
The White House did not immediately respond when asked if Mr. Trump ever tried courting Democratic members in the House.
Mr. Trump claimed Obamacare was 'exploding.'
''I've been saying for the last year and a half that the best thing we can do politically speaking is let Obamacare explode. It is exploding right now.''
This is exaggerated. As Reed Abelson and Margot Sanger-Katz have reported for The Upshot, the Affordable Care Act's insurance markets are not ''exploding,'' ''imploding,'' ''failing,'' ''collapsing'' or in a ''death spiral.''
While there are certainly issues with the current law (for example, high premiums and deductibles), the nonpartisan Congressional Budget Office said in its first estimate of the Republican bill that both it and the Affordable Care Act would stabilize over the long run.
Mr. Trump asserted that there were no Obamacare insurers in parts of Kentucky and Tennessee.
''I was in Tennessee the other day and they've lost half of their state in terms of an insurer. They have no insurer. And that's happening to many other places. I was in Kentucky the other day and similar things are happening.''
This is exaggerated. The competitive situation is not healthy in those two states, but Mr. Trump has overstated the current lack of insurers. But next year, he could be less incorrect.
Congress's Joint Economic Committee reported, using data from the Kaiser Family Foundation, that 43 percent of counties in Kentucky had two insurers, and 49 percent were covered by just one.
Tennessee divides its marketplace into eight areas, three of which have two carriers and five of which have one, according its Department of Commerce.
With Humana pulling out of the A.C.A. marketplaces, 16 counties in Tennessee will no longer have insurers available next year, said Larry Levitt, a senior executive at the Kaiser Family Foundation. ''It's not half the state, but it is a real problem.''
Mr. Trump claimed triple-digit premium increases were common.
''Last year you had over 100 percent increases in various places.''
This is exaggerated. Only one state, Arizona, saw its premiums double (116 percent). Changes in premium costs ranged from a 3 percent decrease in Indiana to a 69 percent increase in Oklahoma (the second highest).
This year, premiums for the benchmark plan rose by 22 percent on average across the states that use the federal marketplace or have their own exchanges, according to the Department of Health and Human Services.
Mr. Trump claimed high increases across the board.
''Many places 50, 60, 70 percent. I guess it averaged -- whatever the average was, very, very high.''
This needs context. Six states -- Alaska, Minnesota, Nebraska, Oklahoma, Pennsylvania and Tennessee -- saw increases in the range Mr. Trump referred to.
As previously stated, the average increase was 22 percent -- compared with a 7 percent increase in 2016 and a 3 percent increase in 2015. But looking at premium increases alone does not fully capture what people are paying. About 84 percent of enrollees qualify for tax credits that will help blunt the costs this year, meaning the government picks up the tab for any increase.
Premium increases affect just 3 percent of all Americans.
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URL: http://www.nytimes.com/2017/03/24/us/politics/fact-check-trumps-misleading-claims-in-health-bill-failure.html
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The New York Times
December 13, 2014 Saturday
Late Edition - Final
Another Baseless Attack on Health Law
BYLINE: By THE EDITORIAL BOARD
SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 18
LENGTH: 459 words
The opponents of the Affordable Care Act have filed another long-shot lawsuit that could undermine health care reform and force many consumers to pay more for health insurance if the suit succeeds.
The Supreme Court has already agreed to hear a separate case, filed by anti-reform forces, that seeks to prevent the payment of tax credit subsidies to help people buy insurance in 36 states where the federal government has established health care exchanges because the state chose not to. If that case succeeds, low- and middle-income people in those states will have to pay a lot more of their insurance premiums.
The new suit, filed late last month by the Republican-dominated House, aims to block another important subsidy: federal payments to insurance companies to keep deductibles, co-payments and other cost-sharing low for the poor. The Affordable Care Act specifies the maximum amounts people will have to pay in cost-sharing based on their incomes, and federal subsidies make up the rest.
If the government is blocked from reimbursing insurers for the subsidies, the insurers will have to absorb the costs. But companies might well raise their premiums for everyone else in the individual market to recoup the loss. The House lawsuit argues that no money was appropriated to reimburse insurers for cost-sharing and that the administration could not use money from a separate account that subsidizes premiums.
The Affordable Care Act authorized these cost-sharing subsidies when it was enacted in 2010 and the administration at one point requested an appropriation, but Congress failed to provide it. The House suit argues that it was unconstitutional for the administration to tap the separate fund to pay cost-sharing subsidies that are expected to total $175 billion over a 10-year period.
For the suit to proceed, the House must show that it has standing to challenge the administration's action. Courts often shy away from disputes between Congress and the executive branch. This suit does not even reflect the will of Congress, since it was filed only by the House, not the whole Congress.
The House will have to prove that it was injured by the administration's action and that the injury can be best fixed by the courts rather than by political means. If the courts grant standing, the House will have the additional burden of proving that a specific appropriation for this subsidy is actually required. If the House Republicans prevail and no law appropriating money is enacted, the harm may be significant. Many, if not most, of the people enrolled in health plans on the exchanges are believed to receive cost-sharing subsidies from insurers. If the federal government cannot assist, a lot of other individual policyholders may have to pay more.
URL: http://www.nytimes.com/2014/12/13/opinion/another-baseless-attack-on-health-law.html
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The New York Times
July 29, 2014 Tuesday
Late Edition - Final
Gains Seen for Medicare, but Social Security Holds Steady
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 14
LENGTH: 971 words
WASHINGTON -- Medicare's financial condition improved significantly in the last year, thanks in part to the Affordable Care Act, but the outlook for Social Security is basically unchanged, the Obama administration said Monday.
If Congress makes no change in existing law, officials said, Medicare's hospital insurance trust fund will be exhausted in 2030, four years later than the administration projected in May 2013. The Social Security trust fund, they said, will be depleted in 2033, the same as expected last year.
The forecasts were included in the government's annual report on the two programs, which together account for about 40 percent of federal spending.
Medicare spending on hospital care was lower than expected last year, the administration said, and officials have lowered their assumptions about the use of inpatient hospital services in the future.
Reports from the trustees -- four federal officials and two public representatives -- are largely prepared by career civil servants, who take pains to provide an objective assessment of the programs' finances.
Social Security provides benefits to 59 million people, and, on average, about 10,000 baby boomers become eligible each day. Payroll taxes and other revenue dedicated to Social Security would be sufficient to pay about three-fourths of promised benefits if its trust fund runs out, administration officials said.
The Treasury secretary, Jacob J. Lew, said the reports showed that ''Social Security and Medicare are fundamentally secure.'' But he expressed concern about Social Security's disability program because, he said, its dedicated funds will cover the full amount of promised benefits for only two more years.
Mr. Lew endorsed a stopgap solution, which would temporarily reallocate some payroll tax revenue to disability benefits from the surplus built up for retirement benefits. ''There is probably no other alternative that could provide the desired results'' in the next two years, Mr. Lew said. Congress approved a similar reallocation in the 1990s.
With the aging of the population, the number of Medicare beneficiaries is also growing rapidly.
The financial condition of Medicare has benefited from a slowdown in national health spending, attributed in part to the Affordable Care Act, which curbed Medicare payments to many health care providers and encouraged them to find more efficient ways of delivering care. The slow growth of wages and prices, following the economic recession of 2007-09, was also cited by the trustees as a factor restraining the growth of Medicare.
Two numbers illustrate the slowdown in Medicare spending.
The trustees estimate that the standard monthly Medicare premium will be $104.90 next year, unchanged from 2013 and 2014. In addition, the trustees said that Medicare spending per beneficiary averaged $12,210 last year, the same as in 2012, and it is expected to be about the same in 2015.
However, in the coming decade, average spending per Medicare beneficiary is expected to grow about 40 percent, to $17,360 in 2023, with outlays expected to rise much faster for prescription drugs and doctors' services than for inpatient hospital care.
Jeanne M. Lambrew, a health policy coordinator at the White House, said that in 2009, a year before adoption of the health care law, the trustees predicted that the Medicare trust fund would run out of money in 2017. ''Today's new date is 2030,'' she said, ''13 years later than that projection -- an improvement that is thanks in part to reforms in the Affordable Care Act.''
Robert D. Reischauer, one of the public trustees, said the latest projections still indicated that Medicare spending would grow faster than the economy as a whole, workers' earnings or the incomes of retirees.
''Under current law,'' Mr. Reischauer said, ''both of these very important programs are fiscally unsustainable over the long run and will require legislative intervention.''
Members of Congress have discussed the idea of higher premiums for high-income Medicare beneficiaries and a reduction in the annual cost-of-living adjustments for Social Security. Such proposals often come up in the context of efforts to negotiate a broader agreement on federal spending and taxes, but the prospects of such a deal have shrunk to the vanishing point in this election year.
The trustees' report says that the Social Security trust fund ran a surplus of $32 billion last year and is on track to run another one, increasing its total reserves to nearly $2.8 trillion by the end of this year. The trust fund's assets will decline at a rapid rate starting in about a decade, the report shows.
Representative Dave Camp, Republican of Michigan and chairman of the Ways and Means Committee, said: ''This administration continues to ignore the fast-approaching crisis that Medicare and Social Security face, especially our Social Security disability program. The fact is, without bipartisan action, benefits will be cut.''
Democrats and their allies tend to favor tax changes that could, for example, eliminate the cap on earnings subject to the Social Security payroll tax.
''If Congress listens to the American people and requires millionaires and billionaires to pay their fair share, the report shows, all benefits can be paid for the next three-quarters of a century and beyond,'' said Nancy J. Altman, co-chairwoman of Strengthen Social Security, a coalition that includes many liberal organizations.
The chief Medicare actuary, Paul Spitalnic, said that future costs could well be higher than indicated in the report. The 2010 health law reduces the growth of Medicare payments to hospitals and many other providers, on the assumption that they will increase their productivity, but, Mr. Spitalnic said, ''there is a strong possibility that certain of these changes will not be viable in the long range.''
URL: http://www.nytimes.com/2014/07/29/us/outlook-for-medicare-trust-fund-improves-though-shortfall-looms-report-finds.html
LOAD-DATE: July 29, 2014
LANGUAGE: ENGLISH
GRAPHIC: CHARTS: A Financial Outlook for Medicare: The latest report from the trustees of the Medicare trust fund projects that the fund will remain solvent for 16 more years, until 2030.
Medicare spending per beneficiary is expected to grow about 40 percent over the next decade, to $17,360 in 2023, with faster growth for prescription drugs and doctors' services. (Sources: Department of Health and Human Services
Social Security Administration)
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The New York Times Blogs
(You're the Boss)
February 22, 2012 Wednesday
How Small Businesses Are Coping With Health Insurance
BYLINE: ROBB MANDELBAUM
SECTION: BUSINESS; smallbusiness
LENGTH: 732 words
HIGHLIGHT: What percentage of employee health insurance premiums does your company pay?
Occasionally in the coming weeks and months, The Agenda will introduce you to small-business owners who are wrestling with how to provide health insurance to their employees. Over time, we hope to delve into all aspects of a crucial decision - not just managing the costs but sorting out benefit packages, weighing alternatives, and dealing with insurers and brokers. Along the way, we hope to get a better understanding of how the 2010 health-care legislation will, or won't, affect small businesses.
Today we meet Ann Gish, who designs high-end bed linens from offices in Manhattan. As we proceed with this series, we'd like to hear from you. What questions would you like us to ask of the business owners we profile? Do you have an interesting health insurance story to tell? Please drop us a line.
THE OWNER Ann Gish, 63.
THE COMPANY Ann Gish Inc. designs and distributes luxury bed and table linens and pillows, which are sold at Bergdorf Goodman, NeimanMarcus.com and boutiques nationwide. In 2011, the company opened its own storein Manhattan. Excluding Ms. Gish and her husband, Ann Gish Inc. employs 10 people in the United States.
WHAT THE COMPANY PAYS The company bears the entire premium cost for its workforce, $472 a month per employee. It provides individual coverage only, but Ms. Gish said that most of her employees are either unmarried or have spouses who get insurance through their jobs. One sales manager, however, has a self-employed husband with a pre-existing condition and a child. Ms. Gish pays the employee's premiums, and the employee pays the insurance for the rest of her family - an additional $1,300 a month. "She used her agent, we used our agent, and this was the best we could do," Ms. Gish said. "If she could find a better deal, we'd give her the $500." Ms. Gish said she is giving serious thought to reducing the share of employee premiums that her company pays: "I want to see what happens business-wise over the next year, and I want to see what happens when the health care reform kicks in."
THE PLAN Ann Gish offers preferred provider organization coverage, a form of managed care that favors doctors and hospitals that are in-network. One aspect of the plan that galls Ms. Gish is that doctors must seek permission from the insurer before prescribing some treatments. However, Ms. Gish said, the plan is "non-gated," meaning that employees don't need permission from their primary doctor to see a specialist.
THE INSURER Currently, it's Aetna; before that, it was Oxford. "We've changed either every year or every two years," Ms. Gish said, "because they take away the policy that you have, and they give you a new one that's more money and generally fewer benefits." In recent years, premiums have bounced around, Ms. Gish said: $422 in 2009, $479 in 2010, back down to $443 last year, and now back up again. Meanwhile, she said, this year employees face slightly higher co-payments and much steeper deductibles.
THE HEADACHE Pounding and relentless. Even simple tasks, she said, like adding or removing employees from the rolls, are complicated: "My husband, who does all of the C.F.O. stuff, has spent hours and hours and hours on this. And I spend a couple days a year on it. And I'm not stupid. I've started a successful business."
WHAT DIFFERENCE THE OVERHAUL HAS MADE SO FAR None. She looked into thehealth care tax credit available to small businesses under the law but found that the average wages her company pays exceed the law's $50,000 threshold for the credit.
WHAT SHE WANTS FROM REFORM Simplification. Health insurance, Ms. Gish said, "should be put together in a way that any idiot could understand." Though Ms. Gish has occasionally read press accounts of how the Affordable Care Act will change insurance, she concedes that she still does not know what to expect. "I figure when 2014 comes, I'll have to learn it," she said. "But since I feel pretty powerless about doing anything, and since it could all change before then, what's the point in trying to sink your teeth into it now?"
Do you have any thoughts on Ms. Gish's situation? What percentage of employee premiums does your company pay?
Business Owners Try to Make Sense of Health Care
Looking to the Affordable Care Act For Help
Further Thoughts on Why Our Health Rates Fell
My Health Insurance Rates Just Went Down Again
For Small Business, Bad News on Health Care Costs Isn't as Bad
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The New York Times
August 12, 2015 Wednesday
Late Edition - Final
Number of Uninsured Has Declined by 15 Million Since 2013, Administration Says
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 11
LENGTH: 723 words
WASHINGTON -- The number of people without health insurance continues to decline and has dropped by 15.8 million, or one-third, since 2013, the Obama administration said Tuesday.
The decline occurred as major provisions of the Affordable Care Act took effect. The law expanded coverage through Medicaid and through subsidies for private insurance, starting in 2014.
In the first three months of this year, the National Center for Health Statistics said, 29 million people were uninsured. That was seven million fewer than the average for 2014, after a reduction of 8.8 million from 2013 to 2014.
The data may bolster Democrats' claims that the law is working as they intended, but it is unlikely to prompt Republicans to let up on criticism of the law, which was passed without any Republican votes.
In a report on its findings, the center said that the proportion of the population without insurance had declined by five percentage points, to 9.2 percent, in the first quarter of this year, from 14.4 percent in 2013.
Among people age 18 to 64, the number who were uninsured dropped by about one-third, to 25.5 million, in the first quarter of this year, from 39.6 million in 2013. And among children under 18, the number of uninsured declined to 3.4 million this year, from 4.8 million in 2013.
The decline in the number of uninsured coincides with improvements in the economy. In the last two years, the recovery has gained traction and the unemployment rate has declined steadily.
The numbers for the first quarter of this year, from the National Health Interview Survey, are estimates based on data for 26,121 people. The information was collected in household interviews by the Census Bureau, using procedures specified by the National Center for Health Statistics, a part of the Public Health Service. The survey focused on the civilian population outside prisons and nursing homes.
The report suggests that the Affordable Care Act produced the most significant gains in coverage among poor people and those with income just over the poverty level, which is $11,770 for an individual.
In the first three months of this year, among poor people age 18 to 64, about 28 percent lacked health insurance, down from 39.3 percent in 2013, the government said. And among people in that age bracket with incomes from the poverty level up to twice that amount, 23.8 percent were uninsured in the first quarter of this year, down from 38.5 percent in 2013.
Gains in coverage were also notable for Hispanics, who have long been more likely than other groups to be uninsured. In the first quarter of this year, 28.3 percent of Hispanics age 18 to 64 were uninsured, down from 40.6 percent in 2013, the government said.
The comparable figures also fell for non-Hispanic black adults, to 15.6 percent from 24.9 percent, and for non-Hispanic white adults, to 8.7 percent from 14.5 percent.
States that expanded Medicaid have seen a sharper drop in the proportion of people who are uninsured, although residents of those states were also more likely to have coverage before the health law took effect. In states that expanded Medicaid, 10.6 percent of people age 18 to 64 were uninsured in the first quarter of this year, down from 18.4 percent in 2013, the report said.
In states that chose not to expand Medicaid, 16.8 percent of such adults were uninsured in the first quarter of this year, down from 22.7 percent in 2013.
A separate study, issued this week by the Gallup organization, found that Texas was the only state where at least 20 percent of people were uninsured. By contrast, it said, in 2013, people without coverage accounted for at least 20 percent of the population in 14 states. Arkansas, California and Kentucky were among the states showing the largest reductions in the proportion of people without insurance.
The data, collected in telephone interviews as part of the Gallup-Healthways Well-Being Index, showed that the uninsured now account for 5 percent of the population or less in seven states: Connecticut, Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island and Vermont.
From 2008 to 2014, Massachusetts was the only state at or below 5 percent, Gallup said. Massachusetts expanded coverage under a 2006 law that was, in some ways, a model for the federal law signed four years later by President Obama.
URL: http://www.nytimes.com/2015/08/12/us/number-of-uninsured-has-declined-by-15-million-since-2013-administration-says.html
LOAD-DATE: August 13, 2015
LANGUAGE: ENGLISH
GRAPHIC: CHARTS: Number of Uninsured Continues to Drop: The Obama administration reports that 9.2 percent of all Americans were uninsured in the first quarter of this year, down from 14.4 percent in 2013, just before major provisions of the Affordable Care Act went into effect. (Source: U.S. Department of Health and Human Services, National Center for Health Statistics)
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The New York Times
March 14, 2017 Tuesday
Late Edition - Final
Policy Expert Will Take Reins at Medicare and Medicaid Agency
BYLINE: By ROBERT PEAR
SECTION: Section A; Column 0; National Desk; Pg. 13
LENGTH: 878 words
WASHINGTON -- The Senate on Monday confirmed Seema Verma, a health policy expert from Indiana, to lead efforts by the Trump administration to transform Medicaid and upend the Affordable Care Act.
By a vote of 55 to 43, the Senate approved the nomination of Ms. Verma to be the administrator of the Centers for Medicare and Medicaid Services, which spends more than $1 trillion a year on programs providing health care to more than one-third of all Americans.
Unlike most people who have held the job, Ms. Verma has extensive experience in Medicaid, a program that was expanded by President Barack Obama's health care law and now provides coverage to more than 70 million low-income people.
Ms. Verma was an architect of Indiana's Medicaid program, widely seen as a model by conservatives, and she worked closely with Vice President Mike Pence when he was the state's governor. Indiana expanded Medicaid eligibility, but emphasized ''personal responsibility.'' That means that beneficiaries pay premiums, contribute to health savings accounts and receive incentives for healthy behavior.
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, said Ms. Verma was ''the ideal candidate to oversee the reform of the Medicaid program,'' as she had worked well with members of both parties in Indiana and in other states.
But Senator Edward J. Markey, Democrat of Massachusetts, said she has supported proposals that ''create roadblocks to coverage for low-income Americans.'' And she would have a major role in carrying out legislation to gut the Affordable Care Act and remake the Medicaid program, said Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee.
A plan by House Republicans, which was released last week, would repeal major parts of Mr. Obama's health care law and would phase out the expansion of Medicaid that has brought coverage to millions of people.
Senate Democrats cast a wary eye on how Ms. Verma might enforce the legislation, if it is approved. Mr. Wyden said she ''would be able to give states a green light to push the very frail and sick into high-risk pools'' in which they could receive substandard coverage or be forced to pay more for the care they need. Senator Maria Cantwell, Democrat of Washington, said Ms. Verma in Indiana ''made millions of dollars in consulting fees by kicking poor, working people off of Medicaid for failure to pay monthly contributions similar to premiums.''
And Senator Debbie Stabenow, Democrat of Michigan, said she was dismayed that Ms. Verma had suggested at her confirmation hearing last month that coverage of maternity care should be optional, not required, as it is now under the Affordable Care Act.
At that hearing, Ms. Verma said: ''Some women might want maternity coverage and some women might not want it, might not choose it, might not feel like they need that. So I think it's up to women to make the decision that works best for them and their families.''
But not all Democrats found fault with Ms. Verma's work on Medicaid in Indiana. Under the program she helped devise, ''hundreds of thousands of Hoosiers currently have health insurance,'' said Senator Joe Donnelly of Indiana, one of three Democrats who voted for her on Monday.
''This plan,'' he said, ''has helped lower our state's uninsured rate and improve health care outcomes, and has played a critical role in combating the opioid-abuse and heroin-use epidemics.''
The Obama administration granted a waiver for Indiana's Medicaid program following lengthy negotiations, and several other states are considering similar changes. Tom Price, the secretary of health and human services, promised last week to give states ''greater flexibility.''
Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said the premiums charged to Medicaid beneficiaries in Indiana, as well as the complexity of the program, appeared to be ''deterring significant numbers of eligible low-income people from enrolling.'' Still, she said, the coverage provided under Indiana's plan is ''better than no coverage at all.''
And without the conservative features of the program, state officials said, Indiana might not have expanded eligibility.
Dennis M. Murphy, the chief executive of Indiana University Health, and top executives of five other hospital systems in Indiana endorsed Ms. Verma, saying in a joint statement that she had shown a knack for ''bipartisan solutions that unite people across the political spectrum.''
The Centers for Medicare and Medicaid Services has led federal efforts to carry out the Affordable Care Act, setting standards for private health insurance and operating HealthCare.gov, the online marketplace on which more than 10 million people obtained coverage last year.
Ms. Verma has comparatively little experience with Medicare, the popular program that insures 57 million people who are 65 or older or have disabilities. Within a decade, enrollment is expected to grow by one-third, to 76 million. As a presidential candidate, Mr. Trump said he did not intend to cut Medicare or Medicaid.
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URL: http://www.nytimes.com/2017/03/13/us/politics/seema-verma-medicaid-medicare-administrator.html
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The New York Times
June 26, 2015 Friday
Late Edition - Final
The Justices Rule on the Health Law
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 403 words
To the Editor:
The Supreme Court has read some sloppy legislation in a way most beneficial to millions of Americans now covered by medical insurance with the help of a federal subsidy. Many politicians will also benefit as a result.
Since the passage of the Affordable Health Care Act, Republican opponents of the Obama administration have made the act Public Enemy No. 1. However, as affordable health care has begun to settle in, its political value as a target has increasingly waned.
Had the Supreme Court negated the federal subsidy system, Republican candidates would have had to answer for the mayhem that was sure to follow. The court's sane reading of the act has removed that political burden.
More important, the nation should now be able to move forward with insured health care as a permanent part of the lives of millions of Americans previously left by the side of the road. There will, I hope, be improvements to come, but the debate should now forever turn from health care as a privilege to health care as an entitlement and how best to maintain it.
BRUCE NEUMAN
Sag Harbor, N.Y.
To the Editor:
The Supreme Court accepted a case that was based on the notion that a few ambiguous words in a law -- ''an exchange established by the state'' -- meant that the law did not mean what the people who wrote it and those who voted for it thought it meant. Three justices were willing to support that point of view. That is truly shocking, and demands as much public scrutiny as the practical impact of the case.
HOLLIE CONLEY
New York
To the Editor:
I did not begin to expect this outcome and find myself experiencing a range of emotions, foremost among them gratitude, followed by a sharp sense of surprise.
The surprise saddens me, as it reflects how deeply ingrained is my sense of low expectations for this Supreme Court, and for this Congress. Six justices should stand a little straighter, walk a little taller and realize that on this day, they did their jobs with honor, integrity and compassion. Well done. Thank you.
SUSAN OVERSTREET
Los Altos, Calif.
To the Editor:
Politics aside, this ends a frightening time for hundreds of thousands of people kept awake nights by fear that after the Supreme Court ruling, they would not be able to afford health insurance. I'm sure that people are crying with relief today. Life can be so scary without health insurance.
RICHARD GRAYSON
Brooklyn
URL: http://www.nytimes.com/2015/06/26/opinion/the-supreme-courts-ruling-on-the-health-law.html
LOAD-DATE: June 27, 2015
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The New York Times
December 3, 2013 Tuesday
Late Edition - Final
HealthCare.gov: Flaws and Fixes
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 26
LENGTH: 575 words
To the Editor:
Re ''Inside the Race to Rescue a Health Site, and Obama'' (front page, Dec. 1):
The grossly flawed rollout of HealthCare.gov points up not merely substandard information technology project management skills but also a systemic inability to ''speak truth to power'' throughout the administration.
Competent people knew that HealthCare.gov lacked proper stress testing, just as others knew that many individual health insurance plans would be canceled under the Affordable Care Act. Those who blocked such communications to or from the Health and Human Services Department and the White House must be taught to do better.
DAVID OCHROCH Arlington, Va., Dec. 2, 2013
The writer was senior director of I.T. procurement for Sallie Mae, the student loan program, from 1991 to 2000 and an I.T. consultant to the College Board.
To the Editor:
In your excellent article about the woes of the health care website, one thing stood out: a decision was made early on not to hire a ''systems integrator.'' This is like putting on a symphony without a conductor.
Jeffrey D. Zients, the presidential adviser leading the repair effort, is the only hope for fixing the website. But to overlook the assignment of a systems integrator -- a conductor -- at the outset seems like nothing short of negligence.
The private sector deals with this successfully every day. The government's negligence is absolutely shameful.
JOE HALEY Danville, Calif., Dec. 1, 2013
To the Editor:
It was only after the rollout date and after the system had crashed and burned that President Obama spent 90 ''excruciating'' minutes learning about all the problems.
I understand that the president has a very busy job, but how could he have been unaware of so many serious problems? And more concerning, of what else isn't he aware?
ANDREA ECONOMOS Scarsdale, N.Y., Dec. 1, 2013
To the Editor:
HealthCare.gov was badly designed but can be made to work. Computers today are so powerful that they compensate for clumsy software design.
Social Security and Medicare are now excellent websites, but they certainly had problems at first.
By next summer, HealthCare.gov and the Affordable Care Act might be gaining widespread acceptance. Will the Republicans then be calling them bad ideas? More important, will we begin recovering from our ''prediction addiction''?
DAVID L. HAGAN Grover Beach, Calif., Dec. 1, 2013
To the Editor:
Your article describes a ''frantic effort aimed at rescuing not only the insurance portal and Mr. Obama's credibility, but also the Democratic philosophy that an activist government can solve big, complex social problems.''
That philosophy does not need rescue.
Medicare has proved for half a century that the federal government can provide universal health care to those over 65. And numerous national governments in Europe and Asia provide universal health care to all with high quality and lower cost.
Some of them (like Germany) do so with regulated insurance markets and risk-based subsidies, similar to the Affordable Care Act.
What activist government needs is a political system with the attention span to look past the inevitable initial stumbles to the examples of how it does work.
JIM WHITEHEAD Mercer Island, Wash., Dec. 1, 2013
To the Editor: So let me get this straight: The Republicans' objection to Obamacare is that it's a horrible socialist policy that will destroy America and that it's taking too long to get going? DAVID MISCH Santa Monica, Calif., Dec. 1, 2013
URL: http://www.nytimes.com/2013/12/03/opinion/healthcaregov-flaws-and-fixes.html
LOAD-DATE: December 3, 2013
LANGUAGE: ENGLISH
GRAPHIC: DRAWING (DRAWING BY LUKE RAMSEY)
DOCUMENT-TYPE: Letter
PUBLICATION-TYPE: Newspaper
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The New York Times
July 11, 2014 Friday
Late Edition - Final
Good News in High Places
BYLINE: By JADA F. SMITH
SECTION: Section C; Column 0; Movies, Performing Arts/Weekend Desk; Pg. 4
LENGTH: 152 words
President Obama may have a future in Hollywood.
A funnyordie.com video starring Mr. Obama and Zach Galifianakis was nominated on Thursday for an Emmy in the outstanding short-format live-action entertainment category.
The ''Between Two Ferns'' interview -- which both promoted and, to the dismay of some critics, lampooned the Affordable Care Act -- will compete against shows like ''Childrens Hospital,'' ''Parks and Recreation,'' ''The Soup'' and the halftime entertainment at the Super Bowl.
The six-and-a-half-minute clip shows the president engaging in a sometimes silly, sometimes awkward approach to spreading the word about his signature health care law.
''Have you heard of the Affordable Care Act?'' Mr. Obama asks Mr. Galifianakis.
''Oh, yeah,'' Mr. Galifianakis says. ''I heard about that. That's the thing that doesn't work.''
He adds, ''Why would you get the guy who invented the Zune to make your website?''
URL: http://www.nytimes.com/2014/07/11/arts/television/good-news-in-high-places.html
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April 1, 2011 Friday
The Economics of Privately Sponsored Social Insurance
BYLINE: UWE E. REINHARDT
SECTION: BUSINESS; economy
LENGTH: 1360 words
HIGHLIGHT: The goals and methods of the health care program based last year, derided by its critics as ObamaCare, is widely misunderstand, an economist writes.
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
On March 23, Senator Ron Johnson, Republican of Wisconsin, marked the first anniversary of President Obama's signing into law of the Affordable Care Act of 2010 by publishing a commentary in The Wall Street Journal, "ObamaCare and Carey's Heart."
He began with a touching celebration of the life-saving operation that had been performed some 27 years ago by highly skilled surgeons on the senator's young daughter, who was born with a serious heart defect. He noted that this undoubtedly expensive operation had been financed by a "run-of-the-mill plan available to every employee of an Oshkosh, Wis., plastics plant."
His commentary suggests that he views this "free market" approach to financing health care as the foundation of our health system's remarkable innovations and achievements.
Senator Johnson's commentary then veered into a sharp broadside aimed at the Affordable Care Act of 2010:
I don't even want to think what might have happened if she had been born at a time and place where government defined the limits for most insurance policies and set precedents on what would be covered. Would the life-saving procedures that saved her have been deemed cost-effective by policy makers deciding where to spend increasingly scarce tax dollars?
Not surprisingly, this comment elicited much criticalcommentary, some of it needlessly vehement.
I do not wish to join that a vituperative chorus, because there is much I admire in the senator. He worked hard in his youth to put himself through the University of Minnesota and studied at night for a master's of business administration, and he eventually risked his own money and used his vision and even harder work as an entrepreneur to please customers worldwide and, in the process, create a good livelihood for his family and for his employees. I look up to such entrepreneurs. We all should.
Even so, I am puzzled about why the senator does not see in the Affordable Care Act a sincere attempt to replicate his family's fine health care experience for millions of low-income, uninsured Americans.
The idea is to help those with family incomes above 133 percent of the federal poverty level (currently about $30,000 for a family of four) procure - on an organized state- or federally run health-insurance exchange - community-rated, publicly subsidized, private health insurance of the sort that financed his daughter's cure.
A government-run health insurance exchange is not such a novel idea, nor should it be controversial. The federal government's Office of Personnel Management has for decades run such an exchange for every member of Congress and for federal employees, and very successfully, by all accounts.
To see why the Affordable Care Act is actually trying to mimic employment-based private health insurance, let me propose this definition: Employment-based group health insurance, American style, is publicly subsidized, privately sponsored, community-rated social insurance sold to American employees on formally organized health insurance exchanges.
Let me explain how I come to this definition.
First, economists are virtually unanimous that the bulk of the cost of fringe benefits -- including health insurance -- that is ostensibly covered by an employer is actually taken out of the paychecks of employees collectively, if not year by year then in the long run. Exactly what fraction of the cost is shifted back to employees in this way depends on a number of factors.
As I jokingly put it to my students, employee-benefit managers, basically kindly social workers camouflaged in business attire, are similar to pickpockets who take money out of your paychecks and then use it to buy you health insurance, for which you thank them profusely.
In other words, the employees actually pay most or the full premiums for their employment-based health insurance, even if they do not make an overt contribution toward the insurance premium.
Second, to assist employees in making this purchase, the benefit managers organize a formal health-insurance exchange that lists a side-by-side comparison of the different insurers among which employees can choose.
While there are some variations in the benefit packages offered by the various insurance companies on the list, the packages are typically dictated by the employee-benefit department, which also selects the health insurance plans permitted to list themselves on the exchange (and those that are not) and tightly regulates these companies' behavior during and after the enrollment period.
Of course, smaller companies usually list fewer and sometimes only one or two insurers on their exchanges. Part of the intent of the Affordable Care Act is to offer these small employers access to the larger state-run exchanges, so their employees have more choices among insurers.
Third, the contributions employees make directly toward the premium for health insurance (through explicit deduction from their paychecks), plus their indirect contribution through reductions in take-home pay, are effectively community rated. This means healthier employees are forced to subsidize through their premiums the health care of sicker employees by effectively paying the same premiums.
Consider two workers performing the same work in a company, one healthy and the other chronically sick. They will make the same direct contribution to the identical insurance policy and receive the same take-home pay.
In other words, the idea that raised so many hackles last year - that younger, healthier Americans should, through community-rated health-insurance premiums, subsidize sicker Americans - has long been accepted by the bulk of Americans at their place of work.
In this sense, then, private employment-based group insurance qualifies for the label of "social insurance," even though it is privately sponsored. It is, of course, not socialized medicine, but neither are the Medicare, Medicaid and Tricare programs, government-sponsored social insurance programs that procure health care from the private sector.
Only the program that Americans reserve for military veterans, and apparently preferred by them - the vast Veterans Administration Health System - is pure socialized medicine.
Finally, Americans who procure health insurance at their place of work receive generous public subsidies toward that purchase, and higher-income earners receive larger subsidies than lower-income earners. This is so because the contributions employers make toward the group health-insurance premiums of their employees are tax-deductible business expenses, but not taxable compensation to the employee - even though it is a form of compensation.
Estimates of the total dollar amount of that subsidy range between $200 billion and $300 billion a year, depending on what taxes are included in the analysis - only federal income taxes, or also payroll taxes, or also state income taxes, if any. Estimates consistently show that high-income earners receive the bulk of that public subsidy.
The current amount of that subsidy is estimated at around $200 billion a year, although some estimates go higher, depending on what taxes are included in the analysis -- only federal income taxes, or also payroll taxes, or also state income taxes, if any.
Estimates consistently show that high-income earners in high marginal tax brackets receive the bulk of that public subsidy.
Having said all this, I ask you to imagine a low-income family whose head or heads of household work at very low wages in small companies that do not offer their employees health insurance, which is the case at many small companies. Suppose their little daughter was born with exactly the same condition as was Senator Johnson's daughter. What should the fate of that little girl be?
Perhaps the senator could provide some commentary on that, as well.
Health Reform, the Reward to Work and Massachusetts
Older Workers Could Benefit if Companies Drop Insurance
From Physician Glut to Physician Shortage
Where 'Socialized Medicine' Has a U.S. Foothold
Health Care: Solidarity vs. Rugged Individualism
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(First Draft)
December 24, 2015 Thursday
Bernie Sanders Criticizes Hillary Clinton on Health Care and Campaign Finance
BYLINE: MAGGIE HABERMAN
SECTION: US; politics
LENGTH: 551 words
HIGHLIGHT: “What is stopping us from guaranteeing free, quality health care as a basic fundamental right for all Americans? I believe the answer ties into campaign finance reform,” Senator Bernie Sanders said, suggesting that he is stronger on such issues than Hillary Clinton.
Senator Bernie Sanders invoked the indicted pharmaceutical executive Martin Shkreli in a fund-raising email linking campaign finance and the availability of affordable health care to suggest he is stronger on the issues than Hillary Clinton.
"What is stopping us from guaranteeing free, quality health care as a basic fundamental right for all Americans? I believe the answer ties into campaign finance reform," Mr. Sanders said in the email, which went out this week. "The truth is, the insurance companies and the drug companies are bribing the United States Congress."
He said that he wants to make "health care a right for every American," and that the health care industry is "flooding my opponents with cash."
"Now, I don't go around asking millionaires and billionaires for money. You know that," Mr. Sanders wrote. "I don't think I'm going to get a whole lot of contributions from the health care and pharmaceutical industries. I don't like to kick a man when he is down, but when some bad actors have tried to contribute to our campaign, like the pharmaceutical C.E.O. Martin Shkreli who jacked up the price of a lifesaving drug for AIDS patients, I donated his contribution to an AIDS clinic in Washington, D.C."
He went on to say that Mrs. Clinton, the Democratic Party's front-runner for president in most polls, has received "millions of dollars from the health care and pharmaceutical industries" and more this campaign cycle those sectors than did the top three Republican presidential candidates combined.
"Let's not be naïve about this, maybe they are dumb and don't know what they are going to get?" Mr. Sanders added. "But I don't think that's the case, and I don't believe you do, either."
Mrs. Clinton has received many thousands of more dollars from the health care industry than Mr. Sanders has, according to breakdowns from the Center for Responsive Politics. She was also deeply critical of Mr. Shkreli over the increased cost of a vital AIDS drug when the issue first surfaced in the news media.
In a statement, Christina Reynolds, a spokeswoman for Mrs. Clinton, said her candidate "takes a back seat to no one when it comes to fighting to expand quality, affordable health care coverage for all Americans. She has spent her entire career standing up to the insurance industry and drug companies - and she has the scars to prove it."
She pointed to Mrs. Clinton's effort on a universal health care initiative in 1993 when her husband Bill Clinton was president, and noted the Children's Health Insurance Program grew out of that. She also said Mrs. Clinton wants to improve on the Obama administration's Affordable Care Act.
Asked about the tone of the fund-raising email, a spokesman for Mr. Sanders, Michael Briggs, replied: "Taking factual note of the huge role the health care industry is playing in Secretary Clinton's campaign is consistent with the senator's honest and straightforward critique of her Wall Street donors. These are matter-of-fact contrasts between the kind of contributions that are going to the two candidates. Voters have every right to consider how a candidate's donations would affect policies."
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LOAD-DATE: December 24, 2015
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October 30, 2014 Thursday
Late Edition - Final
The Health Law: A Progress Report
SECTION: Section A; Column 0; Editorial Desk; LETTERS; Pg. 30
LENGTH: 511 words
To the Editor:
Re ''Is the Affordable Care Act Working?'' (front page, Oct. 27):
The Affordable Care Act is not ideal. Republicans point out the damage done to those who get caught in the coverage loopholes that raise their premiums or make them give up their subpar but less expensive coverage. Democrats point out the program's failure to cover all people who need insurance.
The truth is that the A.C.A. was the best plan that could be managed given the political realities. And over all, it is working. More people are insured, costs haven't risen dramatically and it hasn't blown a hole in the budget.
If the mostly Republican governors in the 23 states that refused to expand Medicaid coverage were not preventing that extension out of spite, millions more Americans would be covered, and the benefits of the A.C.A. might be even more pronounced.
The bottom line: It's had a positive impact, and it's only been in existence for a year. Give it time, elect politicians who want to improve it, not destroy it, and see what happens over the next four years.
BRIAN BRUCE Friendswood, Tex., Oct. 27, 2014
To the Editor:
My Blue Cross Blue Shield policy is scheduled to be canceled next summer because of Obamacare. We were promised that this would not happen. I have a very good policy with a low deductible. I have no pre-existing illnesses, but I want to have a choice in my medical providers, as I have always enjoyed. That is important to me as a former health care provider myself.
I do not qualify for a subsidy and was quoted a new premium that is close to 100 percent more than what I pay now (from $501 a month to just under $1,000 a month) for an individual policy. And to add insult to injury, from a $250 deductible to a $6,000 deductible. This is squeezing the middle class.
BARBARA SIBLEY Key Largo, Fla., Oct. 27, 2014
To the Editor:
For me and my family, the proof is in the pudding. As a small-business owner, I saw my family's monthly premium spike to $2,100, after I had several major back surgeries. Under the Affordable Care Act, we now pay $699 per month with superior coverage. Something is working.
It also seems likely that health care costs will actually go down at some point. The insured have been absorbing the costs of the uninsured, who numbered about 47 million before the A.C.A. took effect. As that number decreases, premiums will dive. Just wait.
RANDY WATSON Atlanta, Oct. 27, 2014
To the Editor:
The primary benefit of the Affordable Care Act is a more mobile rank-and-file work force. No longer are workers chained to a particular employer for health insurance benefits.
The A.C.A. allows employees who want to leave the company the solace of health insurance at a reasonable cost. It also allows insurance for those who want to work part time, since most employer-sponsored plans cover full-time workers only.
It is no wonder that companies that depend on cheap labor resist the A.C.A. They will have to pay more to keep their employees, who are now unshackled from the companies' health care plans.
WAYNE CAGLE Jr. Kansas City, Mo., Oct. 27, 2014
URL: http://www.nytimes.com/2014/10/30/opinion/the-health-law-a-progress-report.html
LOAD-DATE: October 30, 2014
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